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

We decided that the Plan does not have to pay for catheterization for collection of urine specimens (multiple patients) provided on November 11, 2019.
You asked the Plan to pay for specimen collection. You say that you are a reference laboratory and the only medical records that you can supply and the ordering requisition and results. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the service billed.
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 P9615 is catheterization for collection of urine specimen(s) (multiple patients). We find that CPT code P9615 is not supported in the medical record. Specifically, the documentation submitted does not show that this service was performed by this provider. Based on this information, we decided that Medicare rules for coverage of specimen collection have not been met. Therefore, we decided that the Plan does not have to pay for catheterization for collection of urine specimens (multiple patients) provided on November 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February
26, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that your wife could have driven
you and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed
correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the
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 ambulance services
provided on February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided from January 31, 2019 to August 22, 2019.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says that they should not be liable for the dental services provided by a Medicare Opted-Out provider.The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a provider who is not enrolled in the Medicare Program.The services were not provided by a provider who is enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay forthe dental services provided from January 31, 2019 to August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 20, 2019 to January 13, 2020 by an out of network (OON) 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 an out-of-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 November 20, 2019 to January 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe post stabilization inpatient care provided to the enrollee from February 3, 2020 through February 4, 2020.You asked the Plan to pay forthe post stabilization inpatient care. You say that inpatient level of care is supported.ThePlan denied your request. The Plan says that the enrollee was stable for transfer. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post stabilization inpatient care. Our reviewer says that that inpatient care was not medically reasonable and necessary for the enrollee in this case. The enrollee was admitted and received medical treatment. Her condition stabilized and improved with therapy. From February 3 through February 4, 2020, there were no new events. Vital signs and labs were stable. The enrollee was stable for transfer to rehab. The treating physician did not document (in the physician notes, on a form, or in an order) that the patientwas not stable for transfer on any dates of service. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for post stabilization inpatient 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 post stabilization inpatient care have not been met.Therefore, we decided that the Plan does not have to pay forthe post stabilization inpatient care provided to the enrollee from February 3, 2020 through February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 12, 2020.
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 physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 drug testing rendered on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) and therapeutic services (97112, 97140, 97530) provided on January 10, 2020 to February 2, 2020.You asked the Plan to pay for extraspinal chiropractic manipulation and therapeutic services. You say that these services improve the condition of your life.The Plan denied your request. The Plan says these services are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) and therapeutic services (97112, 97140, 97530) provided on January 10, 2020 to February 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve docetaxel/carboplatin treatment.
You asked the Plan to pre-approve docetaxel/carboplatin treatment. You say that the requested docetaxel/carboplatin treatment is medically necessary. The Plan denied your request. The Plan says the requested docetaxel/carboplatin treatment is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 docetaxel/carboplatin treatment. Our reviewer says that the requested docetaxel/carboplatin treatment is not medically necessary. Our physician reviewer found the enrollee is with castration resistant metastatic prostate cancer who has previously had treatment progression on Docetaxel. The use of this combination is not FDA approved. The use of this combination is not supported in any of the CMS approved compendium. The NCCN compendium supports the combination specifically to treat small cell/neuroendocrine prostate cancer. The submitted records do not indicate that the enrollee has small cell/neuroendocrine prostate cancer. This reviewer found a later article, Bouman-Wammes, Eur J Cancer. 2018 Feb;90:1-9. This study comparing Docetaxel to Docetaxel plus Carboplatin in men with prior Docetaxel treatment was terminated early due to insufficient recruitment. The authors conclude: This early terminated study suggests no benefit from the addition of Carboplatin to Docetaxel re-treatment in patients with mCRPC, whereas the combination resulted in more toxicity. The use is not listed as not indicated, not supported or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of docetaxel/carboplatin treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve docetaxel/carboplatin treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the remote cardiac monitoring provided on February 26, 2020.
You asked the Plan to waive the coinsurance for the remote cardiac monitoring. You say that the provided equipment was not functional. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 30% coinsurance for out-of-network outpatient diagnostic tests. The enrollee has been asked to pay $218.23, which is 30% of the allowed amount for the remote cardiac monitoring. The allowed amount is $727.44 (30% x $727.44 = $218.23). The remote cardiac monitoring falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the remote cardiac monitoring was provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the remote cardiac monitoring provided on February 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Physical therapy, occupational therapy, and speech therapy on October 1, 2019 to October 30, 2019.You asked the Plan to pay for the therapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized. There were network providers available.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 service 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 the Physical therapy, occupational therapy, and speech therapy on October 1, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 11, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you did not know that this was a Medicare replacement plan or that you should be concerned with which providers are in-network or out-of-network.The Plan denied yourrequest. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 forthe medical services provided on February 11, 2020 by an out of network (OON) 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 with an oxygenator or heat exchanger (99190) provided on June 18, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the medical services.
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan has not provided any documentation for review.
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. Specifically, the Plan has failed to provide a complete case file after two
attempts were made to resend with multiple options of how to send. To date we have not received a case file
and are unable to determine if the Plan's denial is correct based on Medicare criteria. Therefore, we decided
that the Plan has to pre-approve the medical services.
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: Unfavorable

We decided that the Plan does not have to reimburse you for the face-down positioning device provided from November 14, 2019 to November 21, 2019.You asked the Plan to reimburse you for the face-down positioning device. You say that your doctor recommended the vitrectomy support equipment after surgery.The Plan denied your request. The Plan says face-down positioning devices are not covered by Medicare or the Plan.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 a precautionary device not covered by Medicare.Therefore, we decided that the Plan does not have to reimburse you forthe face-down positioning device provided from November 14, 2019 to November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe chest x-ray provided on October 30, 2019.You asked the Plan to waive the copayment forthe chest x-ray. You say that you received a mammogram and not a chest x-ray. You say there should be no 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 x-rays services inan outpatient hospital facility. You have been asked to pay a $50 copayment for the chest x-ray. The chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you receiveda chest x-ray with two views.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe chest x-ray provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided on January 27, 2020 and February 10, 2020.You asked the Plan to waive the copayments for wound debridement. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly,and you are not responsible to pay the denied charges.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 $65 copayment for out-of-network physician/practitioner services, including doctor's office visits. You received wound debridement from an out-of-network provider on January 27, 2020 and February 10, 2020. Therefore, you are responsible to pay a $65 copayment per each visit. The total amount you owe is: $130. You have been asked to pay the total copayment amount of $130 for wound debridement. Wound debridement 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 copayments for wound debridement provided on January 27, 2020 and February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the walker purchased on July 6, 2019.
You asked the Plan to reimburse you for the walker. You say that after a fall you needed a walker to be able to get around. 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. Therefore, we decided that the Plan does not have to reimburse you for the walker purchased on July 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on February 13,
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.
In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21
drug class(es), including metabolite(s) if performed.
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering
physician) stating exactly what tests were to be performed. 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 G0482 provided on February 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 9, 2020 by a non-participating 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-participating 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 January 9, 2020 by a non-participating provider.