Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit.

You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you feel that asking to have a prescription refilled should not warrant a copayment. 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 $5 copayment for primary care provider visits.

The record shows that you received services beyond an annual wellness visit. Therefore, you are responsible to pay the $5 copayment.

You have been asked to pay a $5 copayment for an office visit. An office 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 an office visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic colonoscopy for the enrollee.

You asked the Plan to pre-approve this service. You say that a diagnostic colonoscopy is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for a diagnostic colonoscopy. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the review indicates that a colonoscopy was performed. It stated a 0.2 cm [2 mm] polyp was found which was removed via snare polypectomy and a diminutive polyp which was a removed via cold biopsy forceps. There is an associated pathology report which showed an adenomatous polyp in the sigmoid colon as well as low grade dysplasia consistent with a tubular adenoma in the ascending colon. The recommendation is to repeat the surveillance colonoscopy in five years. There are office visit notes by the provider stating the enrollee had a colonoscopy and was found to have polyps-adenoma with low grade dysplasia. The enrollee has no current symptoms. There is no specific clinical rationale for the requested colonoscopy. Medicare coverage criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic colonoscopy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (K0553).

You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that this service was medically necessary. The Plan denied your request. The Plan says they do not have enough information to decide if the services were medically necessary.

The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).

You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary. The Plan denied your
request. The Plan says daily picture studies cannot be approved because only weekly picture studies are needed
which is included in the approved 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 IGRT. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize
the target to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when
generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of
normal tissues exposed to radiation.

For radiation in the palliative setting, IGRT could be considered medically necessary when it is necessary to
escalate the dose (i.e., oligometastases), particularly when using very high dose per fraction, or when critical
normal tissues abutting the target necessitate daily image guidance to allow minimal planning margins to spare
the normal tissue. In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would
afford. It appears IGRT is simply being used as routine practice, as there does not seem to be any exceptional
circumstances with this patient necessitating the need for IGRT.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve Image Guided Radiation Therapy (IGRT) (77263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary immediate denture.

You asked the Plan to pay for the maxillary immediate denture. You say that you would like this service reconsidered for coverage. The Plan denied your request. The Plan says benefits for this service are limited to one time per sixty-month period.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to 1 set every 5 years. The record shows that you received a partial maxillary denture and partial mandibular denture, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the maxillary immediate denture.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD.

You asked the Plan to waive the copayment for an EGD. You say that you thought you were receiving a screening and should not owe a copayment. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You received an EGD. An EGD is considered a diagnostic surgical procedure, not a screening. Therefore, you are responsible to pay the $250 copayment.

You have been asked to pay a $250 copayment for an EGD. An EGD 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 an EGD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve freestyle libre/sensor/flash monitoring system.

You asked the Plan to pre-approve freestyle libre/sensor/flash monitoring system. You say that the item is
medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for a continuous
glucose monitor.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of freestyle libre/sensor/flash monitoring system have not been met.
Specifically, insufficient medical records were submitted to determine the medical necessity of the continuous
glucose monitor. This means the item requested cannot be approved. Therefore, we decided that the Plan does
not have to pre-approve freestyle libre/sensor/flash monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy duty extra wide hospital bed.

You asked the Plan to pre-approve the heavy duty extra wide hospital bed. You say that you would like this service covered by the Plan. The Plan denied your request. The Plan says the request is not medically necessary under Medicare.

The Plan must follow Medicare rules. Medicare rules say that the beneficiary's weight must be more than 350 pounds, but cannot exceed 600 pounds for coverage of a heavy duty extra wide hospital bed. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the heavy duty extra wide hospital bed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the clinic visit and nasal endoscopy.

You asked the Plan to waive the copayment for the clinic visit and nasal endoscopy. You say that there is a coding problem so you would like the claim adjusted. The Plan denied your request. The Plan says the allowed amount is less than your copayment so your copayment is less.

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 $385 copayment for Outpatient Surgery and Other Medical Services.

You have been asked to pay a $300.40 copayment for the clinic visit and nasal endoscopy. This copayment was lower because the allowed amount for the services was lower. The clinic visit and nasal endoscopy fall within the Outpatient Surgery and Other Medical 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 the clinic visit and nasal endoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services.

You asked the Plan to waive the copayment for laboratory services. You say that you were not charged for laboratory services in the past and 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 $50 copayment for laboratory services for outpatient hospital services.

You have been asked to pay a $50 copayment for laboratory services. Laboratory services fall within the outpatient hospital 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 laboratory services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the Esophagogastroduodenoscopy, flexible, transoral; with biopsy (43239).

You asked the Plan to waive the cost-share for the Endoscopy. You say that the cost-share is too high. The Plan denied your request. The Plan says the cost-sharing was 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 have a $250 deductible. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The Plan contract also says that after the deductible is met, you must pay a $100 copayment for each Medicare-covered ambulatory surgical center visit.

The Plan provided documentation verifying that at the time of the service you had $95.22 remaining in your deductible. The total allowed amount for the service was $386.60. You have been asked to pay a total cost-share of $195.22 ($95.22 deductible + $100 copayment = $195.22) for the Endoscopy. This service falls within the Outpatient surgery 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 cost-share for the Esophagogastroduodenoscopy, flexible, transoral; with biopsy (43239).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5260).

You asked the Plan to pay for hearing aids. You say that you were not aware you had to purchase hearing aids from a specific provider. The Plan denied your request. The Plan says hearing aids are only covered from the provider listed in the EOC.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan-specified provider.

We looked at the file and the Plan's rules. The hearing aids at issue were not purchased from the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5260).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate procedure.

You asked the Plan to pre-approve bone marrow aspirate. You say that this service is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because bone marrow aspirate is experimental/investigational in the setting of spinal fusion surgery.

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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show its safety and efficacy. Iliac crest bone graft is the gold standard 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0481 (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 CPT code.

In this case, the CPT Code Manual definition of code G0481 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 drug-specific 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; 8-14 drug class(es), including metabolite(s)."

We find that HCPCS code G0481 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0481) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999).

You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 95999 requires an explanation of the service which is not in 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the record. Specifically, the documentation submitted does not include a concise description of the unlisted CPT code. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an above-knee acrylic socket (L5631), a flexible inner
socket (L5651), and a custom protective cover (L5705).

You asked the Plan to pre-approve an above-knee acrylic socket, a flexible inner socket, and a custom
protective cover. You say that the requested items are medically necessary. The Plan denied your request. The
Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. The rules say that items coded L5631, L5651, and L5705 are not
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of an above-knee
acrylic socket, a flexible inner socket, and a custom protective cover have not been met. Therefore, we
decided that the Plan does not have to pre-approve an above-knee acrylic socket (L5631), a flexible inner
socket (L5651), and a custom protective cover (L5705).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission and bone marrow aspiration for the enrollee.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health problem.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show safety and efficacy of bone marrow aspirate. Iliac crest bone graft is the gold standard procedure for bone graft. An inpatient stay is not needed for this routine single level L4-5 fusion surgery. Observational stay is most appropriate.

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 pay for an inpatient admission and bone marrow aspiration for the enrollee.