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

We decided that the Plan has to waive the deductible applied for the physician services provided on March 1, 2021. We also decided that the Plan does not have to waive the copayment for the office visit (99213) and the deductible applied for the arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance (20610) provided on March 1, 2021.  

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the cost share has been applied correctly to the services provided.

We decided that the Plan has to waive the deductible applied for the physician services rendered for the arthrocentesis (20610) provided on March 1, 2021. The Plan contract states that the yearly deductible does not apply to physician specialist services provided. Therefore, we decided that the Plan has to waive the deductible of $43.99 for the physician services provided on March 1, 2021.

We also decided that the Plan does not have to waive the copayment for the office visit (99213) and the deductible applied for the arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance (20610) provided on March 1, 2021. The Plan contract says that there is a $245 deductible that enrollees must pay each calendar year. The Plan allowed amount of $233.98 pertains to the deductible for the surgery performed, as you had not previously met the yearly deductible. The Plan contract also says that enrollees must pay a $25 copayment for each Medicare-covered specialist visit. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99213) and the deductible applied for the arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance (20610) provided on March 1, 2021. Additionally, we decided that the plan has to reduce your total cost-sharing responsibility for these claims from $273.30 to $258.98.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on January 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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. Medicare rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.

We asked our coder 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 use of code 99199 is not supported by the records provided. Our reviewer found that the provider states "CPT 99199 reflects the services provided by our Post-anesthesia Care Unit (PACU) Nurse." Per CMS guidelines "The Anesthesia care package consists of preoperative evaluation, standard preparation, and monitoring services, administration of anesthesia, and post-anesthesia recovery care." 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 99199 have not been met. 

Additionally, codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on January 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy 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 the records do not show a condition for which this request is allowable.

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 the record indicates that the enrollee has advanced lung cancer and dysphagia. The provided medical records do not indicate that the enrollee has an indication for the requested service as enumerated in the coverage criteria. The elements of the coverage criteria are not satisfied. 

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 wireless capsule endoscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on February 15, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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. Medicare rules also say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.

We asked our coder 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 use of code 99199 is not supported by the records provided. Our reviewer found that the provider states "CPT 99199 reflects the services provided by our Post-anesthesia Care Unit (PACU) Nurse." Per CMS guidelines for Anesthesia Care Package, "The anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post-anesthesia recovery care." 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 99199 have not been met. 

Additionally, codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the services (99199, S1015, S8301) provided on February 15, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the chest x-ray provided on February 4, 2021.

You asked the Plan to pay for the chest x-ray. You say that this was denied as a duplicate claim in error. The Plan denied your request. The Plan says that this was correctly denied as only one chest x-ray was performed and this was paid.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not supported its assertion that payment had already been made for this service. The file contains evidence only of this denied claim, but no evidence of a paid claim for this physician's services. As the Plan did not support that this was correctly denied as a duplicate claim, we find that the non-payment is not substantiated. Therefore, we decided that the Plan has to pay for the chest x-ray provided on February 4, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing exam and an office visit provided by a participating provider on April 6, 2021.

You asked the Plan to waive the copayment for a hearing exam and an office visit. You say that you should not have to pay two copayments. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for hearing services/hearing evaluation and a $45 copayment physician/practitioner services/specialist.

You have been asked to pay a $45 copayment for a hearing exam and a $45 copayment for an office visit. The total amount you are being asked to pay is $90 ($45 + $45 = $90). A hearing exam falls within the hearing services/hearing evaluation benefit category and an office visit falls within the physician/practitioner services/specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a hearing exam and an office visit provided by a participating provider on April 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of cervical spine (72125), emergency ambulance services (A0427), and laboratory tests (80048, 84443, 83090, 85610) provided from November 27, 2020, through April 19, 2021.

You asked the Plan to waive the copayment for a CT scan of cervical spine, emergency ambulance services, and laboratory tests. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $275 copayment for CT scans performed by a provider other than your primary care physician, a $250 copayment for ambulance services, and a $5 copayment for laboratory services.

You have been asked to pay $275 for a CT scan of the cervical spine, and $230.99 for emergency ambulance services. You have been asked to pay $19.50 for 4 laboratory services ($5 copayment each for 3 lab tests + $4.50 for the 4th lab test = $19.50). A CT scan of cervical spine, emergency ambulance services, and laboratory tests falls within the outpatient diagnostic test and ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of cervical spine (72125), emergency ambulance services (A0427), and laboratory tests (80048, 84443, 83090, 85610) provided from November 27, 2020, through April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.

You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 Vertiflex Superion Interspinous device. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 3, 2021, to March 26, 2021.

You asked the Plan to pay for these services for the enrollee. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, the provider must submit these claims to Original Medicare first before they can be reviewed by the Plan.

Original Medicare must provide the Plan with an explanation of benefits reflecting their coverage decision before the Plan can determine if any further payment is required by the Plan.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from January 3, 2021, to March 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain (70553).

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 coverage criteria has not been met.

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 the MRI is not medically necessary. Our physician reviewer found the record indicates the enrollee has a diagnosis of narcolepsy. The record indicates the enrollee has previously had cranial imaging. The provided record does not indicate that the enrollee has had any acute change or how the requested test would alter management. 

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 brain (70553).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on March 2, 2021.

You asked the Plan to pay for genetic testing. You say that this testing provides the information necessary to make informed decisions. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that genetic testing code 0013M is not covered for date of service March 2, 2021. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a treadmill.

You asked the Plan to pre-approve a treadmill. You say that because of your medical condition it is very hard for you to live a healthy lifestyle without being active. The Plan denied your request. The Plan says exercise equipment is not covered for any condition because it is not used for a medical reason.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a treadmill.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided by on April 27, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that an ambulance was called and most of the symptoms had passed by the time the ambulance had arrived and all of the symptoms had passed by the time the ambulance left. You say that you felt that it was common sense to refuse transport to the emergency room where you would have waited 4-6 hours and have tests that you did not need and could not afford. The Plan denied your request. The Plan says ambulance coverage is a transport benefit and not a covered benefit without transport.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 27, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.

Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be gradually improving but requires additional short-term acute care services which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary at this time as there would be no significant clinical advantage to transfer at this time. Transfer may be considered when treatment has completed.

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 admission to a long-term acute care hospital (LTACH) for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee will not make the significant enough gains necessary to be able to stay at home safely if his care is provided at a lower level of care. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia and was discharged home on August 9, 2021. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DNA/RNA amplified probe (87150) provided on November 9, 2020.

You asked the Plan to pay for the DNA/RNA amplified probe. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not submitted with the appropriate place of service code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DNA/RNA amplified probe have not been met. Specifically, the record indicates that the specimen was collected in an office setting. The claim has been billed with an inappropriate laboratory place of service code. Therefore, we decided that the Plan does not have to pay for the DNA/RNA amplified probe (87150) provided on November 9, 2020.