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

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the
enrollee on June 15, 2020.
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan
says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that HCPCS code is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). Based on this information, we decided that Medicare rules for coverage of have not been met.
Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to
the enrollee on June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 8, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
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 July 8, 2020. 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 the ambulance services provided on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence of a benefit of proton therapy over intensity-modulated radiation
therapy.
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 therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a
heated issue, with quite disparate opinions among experts in the field. Any potential benefit or detriment of
proton therapy over standard IMRT is an investigational question (being pursued in randomized studies- i.e. for
intermediate to low risk prostate cancer. To date, there are no compelling data to suggest that proton therapy is
superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is
to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve proton beam therapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (43235) provided on August 11, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $250 for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $250 copayment for the outpatient hospital surgery provided. 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 Esophagogastroduodenoscopy (43235) provided on August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
July 19, 2020, to July 21, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to
pay the copayment. The Plan denied your request. The Plan says the copayment processed correctly in this
case.
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 $365
copayment each day for days 1-5 for inpatient hospital care.
You have been asked to pay a total cost share of $730 for the inpatient hospital care ($365 copayment x 2
days). The services provided fall within the inpatient hospital care 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 inpatient hospital care provided from July 19, 2020, to July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the medical necessity of
IRF care. The Plan denied your request. The Plan says the clinical information does not show that the
guidelines for coverage of IRF care have been met. The Plan says that the enrollee's needs can be met at a
lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
requires physical therapy and occupational therapy services but does not require an intensive inpatient
rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the coinsurance forthe medical supply provided on October 2, 2020.You asked the Plan to waive the coinsurance forthe medical supply. You say that you are disputing the additional $2.31. You say you believe it is not right to bill more than the standard copayment.The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for medical supplies. ThePlan says you must pay $2.31 for the medical supply. The record shows you were charged for a Part B drug. However, code Q9967 is considered a medical supply. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 10% coinsurance for a medical supply. The Plan contract does not clearly say how much enrollees must pay the medical supply. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the coinsurance forthe medical supply provided on October 2, 2020.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 an outpatient visit provided on March 17, 2020.You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an outpatient visit provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 7, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that modifier 91 may be used to indicate that a test was
performed more than once on the same day for the same patient, only when it is necessary to obtain multiple
results in the course of treatment.
We looked at the file and Medicare rules. The services were billed with modifier 91; however, it is
inappropriate to perform genetic testing more than once in the same day. 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 laboratory services rendered on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says you do not meet all of the prior authorization requirements.
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 monitor. Our reviewer says that the
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided there is no documentation that you have been using insulin.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment a colonoscopy received on October 8, 2020.
You asked the Plan to waive the copayment the services. You say that this was for a preventive colonoscopy.
The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits
and the services rendered.
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 $400
copayment for outpatient hospital surgery services.
You have been asked to pay a $400 copayment for the services. the services falls within the outpatient hospital
surgery 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 a colonoscopy received
on October 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 15, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service. The record shows that a claim for this
service was not filed within the required timeframe. More than one calendar year from the date of service had
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services
provided to the enrollee on July 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute
for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited
number of other physician fee schedule (PFS) services.
The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for
these services to be ordered via telehealth. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on May 28, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a noncovered code.
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel
rendered on May 28, 2020
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the resection of excess soft tissue of the arms.
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan
denied your request. The Plan says that the service is cosmetic and not covered.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
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 service is medically necessary. Our reviewer found the enrollee has functional impairment,
rashes, and pain directly related to her soft tissue excess of the arms. She has failed reasonable conservative
management of her pain. She would likely benefit from the requested procedure. The procedure should be
considered medically necessary and not cosmetic in nature.
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 preapprove the resection of excess soft tissue of the arms.
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 pay fora walker purchased from a non-plan, non-Medicare provider on April 27, 2020.You asked the Plan to pay forthis equipment. You say that this walkerwas medically necessary.The Plan denied your request. The Plan says durable medical equipment purchased outright from non-Medicareeligible providers is not covered.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who is not Medicare eligible. This walker was purchased without prior authorization from a provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay fora walker purchased from a non-plan, non-Medicare provider on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forimmunotherapy service provided on May 14, 2020.You asked the Plan to waive the copayment forspecialist visit. You say that this cost-share was not on the Evidence of Coverage or Annual Notice of Change for 2020.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $35 copayment for specialist visit. You have been asked to pay the allowed amount of $10.36, which is lessthan the $35 copayment for specialist visit. 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 forimmunotherapy service provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesprovided on September 28, 2020.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Planauthorizes use of out-of-network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician'sservices providedon September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 27, 2020, July 2, 2020 and July 31, 2020. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in order for medical services to be covered under your plan, they must be received from providers contracted with the Plan. The only exceptions are in cases of urgent or urgently-needed care, if the medical care required cannot be provided by in-network providers and the Plan has given prior authorization for such care, or for kidney dialysis services obtained at a Medicare-certified dialysis facility when you are temporarily outside the Plan's service area.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on May 27, 2020, July 2, 2020 and July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99292x4) provided on March 19, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration because these services were medically necessary and rendered in good faith. The Plan denied your request. The Plan says the documentation does not support the number of units 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 99292x4 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT code 99292x4 is not supported in the record. Specifically, the record does not indicate that 4 units (120 minutes) or critical care services were rendered in addition to the initial 30 to 74 minutes. The documentation submitted indicates that a total of 88 minutes of critical care services were rendered on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99292x4) provided on March 19, 2020.