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

We decided that the Plan does not have to waive the copayments for the specialist office visit and the electrocardiogram provided on January 13, 2020.
You asked the Plan to waive the copayments for the specialist office visit and the electrocardiogram. You say that you were unaware of your cost share responsibility. You say you were told that the services were approved and covered. 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 each covered specialist office visit and a $55 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a total of $69.21 for the specialist office visit and the electrocardiogram. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefits category. The electrocardiogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" category. See chart below.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Irbesartan-HCTZ 150-12.5mg.
You asked the Plan to pre-approve Irbesartan-HCTZ 150-12.5mg. You say that the medication is necessary.
The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part
D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Irbesartan-HCTZ 150-
12.5mg.
Benefits for Irbesartan-HCTZ 150-12.5mg may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance transports provided to the enrollee on September 13,
2019.
You asked the Plan to pay for the ambulance transports. You say that the enrollee had five separate ambulance
trips on the same date of service. The Plan denied your request. The Plan says that that this is a duplicate
request.
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. You have provided trip records for five different ambulance transports provided
to the enrollee on September 13, 2019. The Plan has not provided proof that they have addressed and paid for
each ambulance transport provided. Therefore, we decided that the Plan has to pay for the ambulance transports
provided to the enrollee on September 13, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on February 21, 2020 by an out of network (OON) provider.You asked the Plan to pay for the vision 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 for the vision services provided on February 21, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening laboratory testing provided on January 21, 2019.
You asked the Plan to pay for lab tests. You say that the tests performed were ordered by referring physician. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the diagnoses billed and were performed for screening purposes.
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 tests at issue in this appeal, lab tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening laboratory testing provided on January 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services (45380) provided by the out of network (OON) provider on October 8, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided 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 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 services at issue. We found no exception that would require the Plan to pay for these services. Additionally, the facility did not submit medical records despite the requests made by the Plan, so it cannot be determined if this was an emergency procedure. Therefore, we decided that the Plan does not have to pay for the colonoscopy services (45380) provided by the out of network (OON) provider on October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 9, 2019 through October 18, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were kept in the hospital longer than needed. You say that it would have been cheaper to approve the skilled nursing. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay you pay $150 per day, days 1-5, $0 per day, days 6-90 and $0 copayment for additional days for each medically necessary covered inpatient stay. You have been asked to pay a $750 copayment for the inpatient stay. ($150/day x first 5 days = $750). The inpatient stay falls 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 stay provided from October 9, 2019 through October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services you received on December 18, 2019.
You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $35 copayment for each specialist visit. Your contract also says that you must pay a 20% coinsurance for Part B drugs. Review of the file shows that you had an office visit and were provided Part B drugs on December 18, 2019. You have been asked to pay a $35 copayment for the specialist visit. The visit falls within the physician services benefit category. You have also been asked to pay a 20% coinsurance for the Part B injection, totaling $15.97. 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 services you received on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6mg Zelnorm tablets.
You asked the Plan to pre-approve the Zelnorm tablets. You say that you would like reconsideration because this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit under the member's medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 6mg Zelnorm tablets.
Benefits for the Zelnorm tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade (J1745).
You asked the Plan to pre-approve Remicade. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Remicade. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Remicade is medically reasonable and necessary or safe and effective for the enrollee. The Medicare-approved compendia do not cite pityriasis rubra pilaris as a medically accepted indication for Remicade. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have to pre-approve Remicade (J1745).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulatory surgery provided on October 8, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for an ambulatory surgery. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that no prior authorization was 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 for an ambulatory surgery provided on October 8,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937), needle electromyography (95886) and nerve conduction studies (95908) provided on November 20, 2019. 
 
You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
 
The CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the neuromonitoring services. Our reviewer says that CPT code 95937 does not meet criteria for billing or reimbursement consideration. The medical records document that Train of Four Testing/Monitoring was performed on November 20, 2019. It is inappropriate to use CPT code 95937 for Train of Four testing.  
 
CPT code 95908 does not meet criteria for billing or reimbursement consideration. The technical report in the medical records provided does not include documentation on a nerve conduction studies; for 3-4studies, therefore this service cannot be validated as being performed on November 20, 2019. The use of pedical screws, as noted in the medical record, does not meet definition criteria for CPT code 95908. Our reviewer found CPT cdode 95886 does not meet criteria for billing or reimbursement consideration. An add-on code is never eligible for payment if it is the only procedure reported by a practitioner. In this case, CPT code 95908, the primary service code was denied by the health plan therefore, CPT 95886 is not eligible for separate reimbursement. 
 
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 neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937), needle electromyography (95886) and nerve conduction studies (95908) provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided February 7 and 8, 2020.You asked the Plan to pay for post-stabilization inpatient hospital. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transport to plan contracted hospital. 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 post-stabilization inpatient hospital. Our reviewer says that rules for coverage were not met. Our physician reviewer found the record shows that the enrollee was stable for ambulance transport to an in-network facility after initial care in the emergency room.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization inpatient hospital have not been met.Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided February 7 and 8, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for craniotomy (62100) provided on August 30, 2019.
You asked the Plan to pay for the craniotomy. You say that you would like reconsideration because this claim is not a duplicate. The Plan denied your request. The Plan says this claim was submitted with an incorrect type of bill code.
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 62100 is not supported in the record. Specifically, a corrected claim should be submitted with type of bill code 217. Based on this information, we decided that Medicare rules for coverage of the craniotomy have not been met. Therefore, we decided that the Plan does not have to pay for craniotomy (62100) provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 15 fractions of intensity-modulated radiation therapy (IMRT). You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the additional 5 fractions are denied as the request exceeds daily treatment dosing limits. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that when anticipated toxicity risks are too high, it is acceptable to consider more standard conventional fractionation (30-35 fractions). A 15-fraction approach is acceptable for locally advanced non-small cell lung cancer (NSCLC), and could also be used for earlier stage NSCLC. The NCCN guidelines discuss 5-10 fraction SBRT regimens as a standard of care for early stage NSCLC. However, this enrollee is not being planned to receive SBRT. The NCCN guidelines do not specify alternative fractionation regimens for early stage NSCLC, though a 15-fraction course for an ultracentral tumor would be within accepted standards of care. Therefore, the requested services are considered medically reasonable and necessary. 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve 15 fractions of intensity-modulated radiation therapy (IMRT). If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerumen removal rendered on December 2, 2019.
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 payable.
The Plan must follow Medicare rules. Medicare rules say that codes with a PC/TC indicator of 5 are not paid when provided to patients in a hospital outpatient department. We looked at the file and Medicare rules. The file shows that procedure code 69209 was billed with a place of service code 23 for an emergency department. This code has a PC/TC indicator of 5 and no separate payment when billed with this location. 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 cerumen removal rendered on December 2, 2019.