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

We decided that the Plan does not have to pre-approve lumbar fusion services.
You asked the Plan to pre-approve lumbar fusion services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar fusion is only covered for certain indications. 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 lumbar fusion services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The documentation does not support instability, fracture, or lesion. The MRI does not show any severe stenosis and instability is not seen on any imaging study. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a replacement power wheelchair.
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that you need a Group 3
power wheelchair. The Plan denied your request. The Plan says you have a power mobility device and there is
no documentation on why you need a replacement or if yours can be fixed.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. Your current power wheelchair is still under reasonable useful lifetime and there
is no repair estimate. Therefore, we decided that the Plan does not have to provide a replacement power
wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 23, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan saysthatthe Plan requires utilization of network providers when possible and available,and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 servicesat 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 a hospital outpatient clinic visit provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on January 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 laboratory services provided on January 23, 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 train of four monitoring (95999) provided on October 10, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this service is considered a bundled procedure as the cost is included in the cost of the primary procedure.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is not eligible for separate payment as it is considered integral to the primary neuromonitoring procedure. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met.Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (E1392).You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable oxygen tanks that you have are heavy and hard to carry, and you are unable to be active and go to the store, work for your church and go on trips.The Plan denied your request. The Plan says you were previously provided with a home oxygen system, including a home oxygen concentrator and portable oxygen tanks, for your oxygen needs within the home.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Medicare does not pay for duplicate equipment  that performs the same function as previously  provided equipment and does not cover additional equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe EGD, flexible, transoral; with biopsy, single or multiple (CPT Code 43239) provided to the enrollee on November 12, 2019.You asked the Plan to pay forthe EGD. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include documentation of Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple; therefore, the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We 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 EGD. Our physician reviewer found the enrollee was slated to undergo an EGD and colonoscopy to evaluate anemia. A pathology report indicates that a colon biopsy was obtained. The actual procedure reports are not submitted for review. Therefore, there is no evidence to support that an EGD with biopsy was performed and, therefore, no evidence to support the billing of CPT 43239 on the DOS in question.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 EGD have not been met.Therefore, we decided that the Plan does not have to pay forthe EGD, flexible, transoral; with biopsy, single or multiple (CPT Code 43239) provided to the enrollee on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forprolonged evaluation and management services (99358) provided on November 2, 2019.You asked the Plan to pay forthe prolonged evaluation and management services. You say that you would like reconsideration based on the records submitted.The Plandenied your request. The Plan says the documentation submitted does not support the billed service.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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the record. Specifically, the record does not indicate that 30 minutes or more beyond the subsequent hospital care level of evaluation and management services were rendered. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management services have not been met.Therefore, we decided that the Plan does not have to pay forprolonged evaluation and management services (99358) provided on November 2, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density scan provided on December 9, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the bone density scan, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the bone density scan provided on December 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay fortrain of four testing (CPT 95999) provided to the enrollee on October 11, 2019.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare guidelines say that this item or service is considered a bundled procedure, as the cost is included in the cost of the primary procedure.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 asked our coding 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 testing. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found train of four testing is included with Intraoperative Neurophysiological Monitoring.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay fortrain of four testing (CPT 95999) provided to the enrollee on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lens, hydrophilic, spherical, per lens (V2520) provided on April 2, 2019 by a non-participating provider.You asked the Plan to pay for the contact lenses. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. We looked at the file and the Plan's rules.Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. The provider is not in-network and your EOC clearly states, routine vision services are only covered when received by a participating provider. There is a $250allowance toward the cost of routine eyewear every year from plan providers.Therefore, we decided that the Plan does not have to pay for contact lens, hydrophilic, spherical, per lens (V2520) provided on April 2, 2019 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study rendered on January 29, 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 procedure code 93971 is 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 93971-26 is duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study.We find that CPT code 93971-26 is not supported in the medical record. Specifically, the records support one unit of this code and the Plan has previously paid for this unit. There is no documentation of an additional study to support billing of one further unit. 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 extremity study rendered on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gym membership fees reimbursement for January 1, 2019 to
October 31, 2019.
You asked the Plan to pay for the gym membership fees. You say that the participating fitness center was very
dirty and took money out of your account that was not due. The Plan denied your request. The Plan says this
benefit is only available through network fitness centers.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits
only when provided through a network fitness centers.
The Plan's rules for coverage of gym benefits have not been met because You must use network fitness centers
for this benefit.. Therefore, we decided that the Plan does not have to pay for gym membership fees
reimbursement for January 1, 2019 to October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on December 18, 2019.You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the genetic testing provided on December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you do not feel responsible for the charges because you were not told that you would be liable for the bill if you were not transported. You say that the ambulance responders had no real urge to take you to the hospital. You stated that theysaid you could stay home if you wanted or they could assist you into your friend's care. You say that your friend ended up taking you.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicarerules. 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 19, 2019. 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 forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 15734 provided on August 12, 2019.
You asked the Plan to pay for CPT code 15734. You say that the medical records support the billing of CPT code 15734. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 15734.
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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk. 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 CPT code 15734. Our reviewer says that the medical records do not support the billing of CPT code 15734. Our physician reviewer found the enrollee was with a diagnosis of Incisional hernia with obstruction, without gangrene. On 8/12/19, the enrollee underwent exploratory laparotomy, with open repair of an incarcerated incisional hernia, placement of mesh, and bilateral rectus muscle advancement flaps. CPT code 15734 is used to describe axial pattern flaps, which include dissection of muscle, disconnection of the origin or insertion of the muscle with preservation of the vascular pedicle, and subsequent transposition of the muscle. CPT code 15734 is not supported by the clinical documentation in the operative report in the case file. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 15734 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 15734 provided on August 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe knee surgery and the physical therapy evaluation provided from June17, 2019 to June 18, 2019.You asked the Plan to waive the cost share forthe knee surgery and the physical therapy evaluation. You say that you thought your bills were paid except for your copayments.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 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $40 copayment for each Medicare-covered in-network physical therapy and speech-language therapy visit. You have been asked to pay a total of $1,940.30 for the knee surgery and the physical therapy evaluation. The knee surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The physical therapy evaluation falls within the "Outpatient Rehabilitation Services" 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 fortheknee surgery and the physical therapy evaluation provided from June 17, 2019 to June 18, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TTE.You asked the Plan to pre-approve the TTE. You say that you would like reconsideration because this test is medically necessary for preoperative clearance.The Plan denied your request. The Plan says echocardiogram is not a recognized preoperative screening test for the indication of diabetes.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 TTE. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria are not met since one coverage limitation includes Echocardiography performed for screening purposes is not covered. 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 TTE have not been met.Therefore, we decided that the Plan does not have to pre-approve TTE.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0676).You asked the Plan to preapprove a pneumatic compression device.You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 4, 2020.
You asked the Plan to pay for the chest x-ray. You say that the service was provided and payment should be
rendered. The Plan denied your request. The Plan says the claim was billed with an outpatient place of service
(POS) when the date of service falls within the enrollee's inpatient confinement. Therefore, coverage criteria
has not been met.
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 71045 is a chest x-ray.
We find that CPT code 71045 is not supported in the medical record. Specifically, the POS code used was 22
which is reported for outpatient hospital, on-campus services. The enrollee was receiving inpatient care on the
date in question. Based on this information, we decided that Medicare rules for coverage of the chest x-ray
have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided
on February 4, 2020.