Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads; interpretation and reportonly (CPT Code 93010) and critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on January 14, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrolleewas under the Medicare hospice benefit for the dates of service at issue in this appeal. The enrollee was enrolled in hospice from January 4, 2019 through January 15, 2019.Therefore, we decided that the Plan doesnot have to pay forelectrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT Code 93010) and critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on January 14, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Herceptin (trastuzumab) as monotherapy.
You asked the Plan to pre-approve the Herceptin treatments. You say that the enrollee will benefit from this maintenance therapy regimen. The Plan denied your request. The Plan says that there is no compendia support of the use of trastuzumab as monotherapy for esophageal cancer.
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 the Herceptin treatments. Our reviewer says that the requested use of Herceptin is considered medically reasonable and necessary. Our physician reviewer found the enrollee is a female with metastatic esophageal cancer. She completed two cycles of cisplatin/taxotere chemotherapy and then six cycles of taxotere/Herceptin. Herceptin is now prescribed for maintenance therapy. Trastuzumab (Herceptin) as maintenance treatment as a single agent for patients with metastatic gastroesophageal cancers is considered a standard of care. This patient has completed primary chemotherapy with Herceptin and will continue on single agent Herceptin. The service is reasonable and medically 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 Herceptin treatments have been met. Therefore, we decided that the Plan has to pre-approve Herceptin (trastuzumab) as monotherapy.
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 medical services provided by the an out-of-network provider from July 23, 2019, to August 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 the medical services provided to E. Counts by an out-of-network provider from July 23, 2019, to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on September 12, 2019 by out of network provider.You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 careand 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 office visit provided on September 12, 2019 by out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approvea Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan.You asked the Planto pre-approvethe FDG PET scan. You say that the enrollee needs this imaging due to her high risk recurrent cancer.The Plandenied your request. The Plansaysthatsince the enrollee has completed anti-cancer treatment, the NCD does not cover this imaging. This is not being requested to determine extent of newly found cancer which means it is noncovered.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 FDG PET scan. Our reviewer says that the requested imaging is medically necessary. Our physician reviewer found the enrollee is a female with recurrent urethral/paravaginal adenocarcinoma. She underwent radical surgery in 2014 with local recurrence in 2017 with radiation and chemo completed in August 2018. She then underwent robotic right lower lobectomy on 1/25/2019 with PET imaging done in March 2019.Per the NCCN Guidelines, PET/CT can be considered as surveillance for recurrence of cervical cancer (vaginal cancer treated as similar) in patients with recurrence. This patient has only had 1 PET scan since completion of most recent therapy. The service is reasonable and medically 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 FDG PET scan have been met.Therefore, we decided that the Planhas to pre-approvea Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan.
Appeal type: Home Health
Decision: Favorable

We decided that the Planhasto pay forhome health services provided to the enrollee on July 31, 2019.You asked the Planto pay forthe services. You say that this was billed correctly.The Plandenied your request. The Plansaysthatthe claim should be resubmitted with the correct bill type.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. The health plan has not adequately clarified how to fix the invalid billing in this case. The plan has not provided enough information in this case, and they have not substantiated their denial.Therefore, we decided that the Planhas to pay forhome health services provided to the enrollee on July 31, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for health club membership reimbursement for the 2018 benefit year.You asked the Plan to pay for health club membership. You say that your original reimbursement request was sent before the deadline but was not received.The Plan denied your request. The Plan says the request for reimbursement was received after the March 31st deadline.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 for qualified health club or fitness facility and reimbursement requests must be received by the plan no later than March 31st of the following year.The Plan's rules for coverage of gym benefits have not been met because the enrollee did not submit the reimbursement request within the required time frame of March 31st. The reimbursement request is dated August 7, 2019.Therefore, we decided that the Plan does not have to pay forhealth club membership reimbursement for the 2018 benefit year.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 11, 2019 to July 13, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that the charges are too high.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 $395 copayment per day for days 1-4 for inpatient hospital care. You had an inpatient hospital stay from July 11, 2019 to July 13, 2019. Therefore, you are responsible to pay a $395 copayment for days 1-2 (July 11, 2019 to July 12, 2019). $395 (copayment) x 2 (inpatient days) = $790.00.You have been asked to pay the total copayment amount of $790.00 for an inpatient hospital stay. An inpatient hospital 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 foran inpatient hospital stay from July 11, 2019 to July 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on June 20, 2019.You asked the Plan to pay for the assembly and operation of a pump. You say that it takes a half hour to an hour to set up the heart lung machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of a pump have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on June 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis provided to the enrollee on September 17, 2019.
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 this is an invalid procedure code for this 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 77062 is "Diagnostic digital breast tomosynthesis; bilateral." We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 diagnostic digital breast tomosynthesis provided to the enrollee on September 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 17, 2019 through February 18, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 17, 2019 through February 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 14, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the increase of 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on May 14, 2019. The total allowed amount is $2,024.57 and 20% of that is $404.92. You have been asked to pay the total coinsurance amount of $404.92 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided on May 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on September 4, 2019 and September 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 97112 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 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.We find that three units of CPT code 97112 is not supported in the medical record. Specifically, the documentation states that a total of 38 minutes was spent providing the services to the enrollee. 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 forthe services rendered on September 4, 2019 and September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction providedon August 5, 2019.You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says services are not covered by the Plan.The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore,we decided that the Plan does not have to pay for an eye refraction providedon August 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a muscle-skin graft (15734) provided on August 16, 2019.
You asked the Plan to pay for a muscle-skin graft. You say that this was billed correctly. The Plan denied your request. The Plan says this code is not supported by the records.
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 a muscle-skin graft. Our reviewer says that CPT code 15734 is not supported by the medical record. Our physician reviewer found the record does not contain evidence that a myocutaneous or fasciocutaneous flap was created and transferred to repair a defect, in accordance with CPT coding rules. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a muscle-skin graft have not been met. Therefore, we decided that the Plan does not have to pay for a muscle-skin graft (15734) provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chiropractic treatment provided on February 8, 2019.
You asked the Plan to waive the coinsurance for the chiropractic treatment. You say that you were told you would not be responsible for the copayments for this service. 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 each visit for Medicare-covered chiropractic services. You have been asked to pay $26.41 which is 20% of the allowed amount for the chiropractic treatment. The allowed amount is $132.05. ($132.05 x 20% = $26.41). The chiropractic treatment falls within "Chiropractic 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 coinsurance for the chiropractic treatment provided on February 8, 2019.
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 your medical team of doctors wants you to continue your recovery in an IRF and for you to be under consistent care for at least a week, because you are at risk for aspiration. You say that you need your doctor nearby for your own peace of mind and anxiety, as well as to make it easier for your family to help in your recovery. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF 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 enrollee's medical conditions appear stable. There are no complex wound care needs. The enrollee does not require the medical oversight of his condition at an acute hospital level of care. There is a primary rehabilitation diagnosis of debility, which does not support the medical necessity of acute level rehabilitation. The enrollee requires physical therapy for mobility and endurance. There is no clear need for occupational therapy. There is no newly identified significant impairing upper extremity condition. The enrollee's debility can be appropriately treated by progressing his mobility with the physical therapy treatments being provided. The enrollee is ambulating household distances with minimal assistance and does not require the intensity of an acute level rehabilitation therapy program. The enrollee would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. The enrollee's care can be appropriately provided at a skilled nursing facility level. 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.