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

We decided that the Plan does not have to pay forthe surgical services rendered on September 24, 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 30903 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 30903 is control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method.We find that CPT code 30903 is not supported in the medical record. Specifically, there is no documentation that an anterior complex control of nasal hemorrhage was performed. There is a more appropriate code for the documented services. 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 surgical services rendered on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 13, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 13, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the reopening of recent laparotomy and negative wound pressure therapy (NWPT) rendered on August 15, 2019 to August 17, 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 that the services are not medically necessary.
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. The rules say that NWPT is covered when specific criteria are met.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee had a splenic and pancreatic injury related to fall requiring splenectomy and distal pancreatectomy. There can be significant edema and swelling that can result in the need to leave the abdomen open to prevent risk of compartment syndrome. In this situation, the planned re-exploration was medically necessary to try and close the abdomen. The enrollee had a traumatic wound and a need for accelerated formation of tissue not achievable by other topical wound treatments. The NWPT is considered the standard treatment to help with traumatic wounds and was 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 these services have been met. Therefore, we decided that the Plan has to pay for the reopening of recent laparotomy and negative wound pressure therapy (NWPT) rendered on August 15, 2019 to August 17, 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 physician's services provided on January 31, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 31, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the deductible for laboratory services provided on February 26, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you never saw the provider ever and disagree with the charges. The Plan denied your request. The Plan says that the claims were processed correctly, and you are being charged the correct amount.
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 Plan did not provide medical records showing whether services were rendered or not. Therefore, we decided that the Plan has to waive the deductible for laboratory services provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 11, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.
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. Medicare specifically excludes coverage of power seat elevation systems coded as (E2300). Based on this information, we decided that Medicare rules for coverage of a power seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services rendered from January 3, 2020 to January 31, 2020.
You asked the Plan to waive the coinsurance for these services. You say that the services should have been taken care of by insurance. The Plan denied your request. The Plan says the coinsurance 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 must pay a 20% coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP.
Review of the file shows that you received dialysis from January 3, 2020 to January 31, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered dialysis services within the service area when ordered by your PCP benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan has not denied coverage of these services. The amount you are being asked to pay is your contractual cost sharing. 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 dialysis services rendered from January 3, 2020 to January 31, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for radiology services provided on February 20, 2020.
You asked the Plan to reduce the copayment for radiology services. You say that you were informed the copayment was $180. You say that the hospital should have known what to charge. The Plan denied your request. The Plan says that the copayment applied correctly.
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. There was no explanation of benefits or claim form submitted with the code at issue to verify the billed services. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for radiology services provided on February 20, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from July 17, 2019 to July 19, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that that there was no indication for sepsis. 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 supports that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient hospital care. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from July 17, 2019 to July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care(99233) provided to the enrollee on December 9, 2019by an out-of-network provider.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 patient was not in an inpatient status for this date of service.The Plan mustfollow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This patient's claim history shows that the patient was in an outpatient hospital observation status for this date of service; therefore, the inpatient Evaluation and Management service has been denied.Therefore, we decided that the Plan does not have to pay forsubsequent hospital care (99233) provided to the enrollee on December 9, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the paring or cutting of a benign lesion provided on March 20, 2020.
You asked the Plan to waive the deductible for the paring or cutting of a benign lesion. You say that you only received a nail trim 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 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 Plan did not provide medical records which are necessary to determine whether services were rendered. Therefore, we decided that the Plan does not have to waive the deductible for the paring or cutting of a benign lesion provided on March 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection provided on January 8, 2020.
You asked the Plan to waive the copayment for the facet joint injection. You say that these are physician visits associated with the hospital, not actually at the hospital. You say that only the facility fees are outstanding. 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 a $275 copayment for Medicare -covered outpatient services at hospital facilities. You have been asked to pay a $275 copayment for the facet joint injection. The facet joint injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the facet joint injection was also billed by the hospital. 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 facet joint injection provided on January 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (H0020) provided January 7, 2019, January 14, 2019 and April 6, 2019 through November 5, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 service 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 outpatient mental health services (H0020) provided January 7, 2019, January 14, 2019 and April 6, 2019 through November 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe office visit and injection services rendered on July 27, 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 thatthe diagnosis is not covered.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 Plan states that the billed diagnosis is not covered; however, the Plan has not provided any documentation or Medicare rules to support that the services are not payable as billed.Therefore, we decided that the Plan has to pay forthe office visit and injection services rendered on July 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyramza solution 100mg/10ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee was already on Avastin, and the disease progressed.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has metastatic colorectal cancer originally diagnosed and treated in 2017. There is no documentation of prior therapy. Cyramza is not indicated for first line treatment. Without documentation of prior treatment it cannot be determined if the the treatment 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Cyramza solution 100mg/10ml for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with
calibrated gradient pressure (E0652) and segmental pneumatic appliance for use with pneumatic compressor,
full arm (E0668), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied
your request. The Plan says the Medicare rules have not been met.
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 DME. Our physician reviewer
found based on the medical records provided the enrollee does not meet the requirements listed in the LCD for
Medicare coverage for E0652 and E0668. There is no documentation of a four-week trial of conservative
therapy demonstrating failed response to treatment with an E0650 or E0651.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) and
segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (HCPCS A4556) provided to the enrollee December 19, 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 a place of service of inpatient hospital is not valid for durable medical equipment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the CPT Code Manual definition of HCPCS code A4556 is "Electrodes, (e.g., apnea monitor), per pair."We find that HCPCS code A4556 is not supported in the medical record. Specifically, this code is a durable medical equipment code and cannot be billed for an inpatient hospital place of service. 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 durable medical equipment (HCPCS A4556) provided to the enrollee December 19, 2019.