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

We decided that the Plan does not have to waive the coinsurance for the alteplase recombinant provided on September 16, 2019.
You asked the Plan to waive the coinsurance for the alteplase recombinant. You say that you only receive a single does every week. The Plan denied your request. The Plan says that there is a 20% coinsurance for Medicare Part B drugs.
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 Part B prescription drugs. You have been asked to pay a 20% coinsurance for the alteplase recombinant. The alteplase recombinant falls 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 the alteplase recombinant provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 4, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed for the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an extended ophthalmoscopy and laboratory services provided on
October 8, 2019.
You asked the Plan to pay for the extended ophthalmoscopy and laboratory services. The Plan denied your request. The Plan says services from non-contracted providers are not covered unless authorized by the Plan.
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 an extended ophthalmoscopy and laboratory services provided on October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 8, 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 claims were billed with an inappropriate modifier.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply. The provider submitted a claim for procedure codes 83880, 85610, 85025, 83615 and 80053 with the -26 modifier. These codes have a PC/TC indicator of 9; therefore, the PC does not apply and is not payable. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an implantation of a sacral nerve stimulator (64561) provided on November 5, 2019.You asked the Plan to pay for an implantation of a sacral nerve stimulator. You say that this should be covered.The Plan denied your request. The Plan says this procedure has not been proven safe and effective.The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention only when the patient is refractory to conventional therapy. 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 an implantation of a sacral nerve stimulator. Our reviewer says that the criteria for coverage of an implantation of a sacral nerve stimulator have not been met. Our physician reviewer found there is no documentation that the patient is refractory to conventional pharmacologic or surgical corrective therapy. Therefore, this procedure cannot be considered 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 an implantation of a sacral nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pay for an implantation of a sacral nerve stimulator (64561) provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture visit you had on August 30, 2019.
You asked the Plan to pay for the acupuncture visit. You say that you saved the plan a lot of money. The Plan denied your request. The Plan says you already reached the benefit limit.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 30 acupuncture visits per year. We looked at the file and the Plan contract. The records show that the benefit limit of 30 acupuncture visits was exhausted on August 23, 2019. The requested visit exceeds the benefit limit. Therefore, we decided that the Plan does not have to pay for the acupuncture visit you had on August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mechanical loosening of internal right knee prosthetic joint.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of physical therapy, and no imaging showing the required conditions.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented on 9/10/19 with an increase in her right knee pain status post a fall. She was status post right Oxford knee replacement on 4/11/16. She was ambulating without assistance with a mildly antalgic, reciprocal gait. Clinical exam findings documented moderate lateral joint line tenderness and painful range of motion 0-100 degrees. There was no clinical evidence of instability, misalignment, crepitus, or muscle atrophy. X-rays of the right knee showed right Oxford hardware in normal alignment, lateral compartment degenerative joint disease, and no acute osseous abnormality. Conservative treatment was prescribed to include activity modification and home exercises. A corticosteroid injection was performed. Under consideration is a 1/2/20 request for partial knee revision to total knee replacement for a diagnosis of hardware loosening right knee. Medicare criteria have not been met. There were no current clinical records submitted subsequent to the 9/10/19 visit. There is no imaging evidence confirming hardware loosening or other Medicare supported indication for revision surgery as outline above. There is no documentation as to the degree of osteoarthritis in the lateral compartment. There is no documentation of recent failed conservative treatment. Therefore, this request for revision right knee surgery is not medically reasonable and necessary 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve mechanical loosening of internal right knee prosthetic joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by a provider other than enrollee's provider.
You asked the Plan to pre-approve the hearing aids. You say that the closest provider is an hour and a half away. The Plan denied your request. The Plan says this is not a covered benefit. The Plan states a representative told you there is a provider about 37 miles away from you.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 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 hearing aids have not been met. You must see your provider to use this benefit. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by a provider other than the enrollee's provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90750 and 90471) provided on October 1, 2019.
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because you were told this service would be covered. The Plan denied your request. The Plan says this vaccine is not covered under your medical benefits but will be covered under your Part D prescription drug benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750 and 90471) provided on October 1, 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and acute respiratory distress syndrome (ARDS). The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee appears to be tolerating ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics provided on May 31, 2019.
You asked the Plan to pay for foot orthotics. You say that you were not aware the orthotics would not be
covered and you confirmed that you are not diabetic. The Plan denied your request. The Plan says this item is
not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics provided on May 31,
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 based on the documentation provided, coverage criteria has not been met.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis following a patellar repair. The enrollee has received repeat surgery. They continue to receive wound care and antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the NCS/EMG testing and extended EEG surgical monitoring of more than one hour (95885, 95907, and 95813). We decided that the Plan does not have to pay for the EEG monitoring during surgery described by code 95955.
You asked the Plan to pay for the NCS/EMG testing and extended EEG surgical monitoring of more than one hour (95885, 95907, and 95813). You say that these codes should be paid. The Plan says that none of the appealed codes are supported in the record.
We decided that the Plan has to pay for the NCS/EMG testing and extended EEG surgical monitoring of more than one hour (95885, 95907, and 95813).
The Plan follows Medicare rules. Medicare rules say that providers must code services correctly. The rules also say that PTP edits are codes that generally should not be billed together unless a clinically appropriate modifier is used. In this case, the documentation does show that EMG/NCS testing was performed during this intraoperative monitoring. There is no clear rationale given by the Plan to support that these are not separately payable. In addition, there is documentation of more than one hour of EEG monitoring which supports the reporting of code 95813. 95813 is a Column 1 code in relation to G0453 (which the plan paid). G0453 was reported with a -59 modifier to signify allowing separate payment as well as payment for code 95813. There is no clear rationale given as to why EEG monitoring is not separately payable in this case. Therefore, we decided that the Plan has to pay for the NCS/EMG testing and extended EEG surgical monitoring of more than one hour (95885, 95907, and 95813).
We also decided that the Plan does not have to pay for the EEG monitoring during surgery described by code 95955.
The Plan follows Medicare rules. Medicare rules say that providers must code services correctly. The rules also say that PTP edits are codes that generally should not be billed together unless a clinically appropriate modifier is used. CPT code 95955 is a Column 2 code in relation to 95813, as 95813 is a more extensive procedure. Although 95955 was billed with modifier -XS, this is not a clinically appropriate modifier. XS signifies that the services were performed on a different structure. As EEG monitoring is done on the whole brain, it is not possible for it to be done on a different structure. The documentation does not support that 95955 is separately payable when billed with 95813. Therefore, we decided that the Plan does not have to pay for the EEG monitoring during surgery described by code 95955.
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 pre-approve a genicular nerve block for the enrollee.You asked the Plan to pre-approve the block. You say that this is medically necessary.The Plan denied your request. The Plan says there is not enough evidence to show that this procedure is safe, and that it works well for knee pain.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 block. Our reviewer says that the requested block is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, the procedure is considered not medically reasonable or necessary 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 block have not been met.Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 26, 2019 through September 29, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on September 26, 2019 and discharged on September 29, 2019. You were asked to pay a $290 copayment per day from September 26, 2019 through September 28, 2019, days 1-3 of your inpatient hospital care. You were discharged on September 29, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $290 copayment per day required for days 1-6. 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 inpatient hospital care from September 26, 2019 through September 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe perfusionist that setup and operated the heart-lung machine during the enrollee's heart surgery provided on September 12, 2019.You asked the Plan to pay forthe perfusionist's setup and operation of the heart-lung machine. You say that it takes a half hour to an hour to set up the heart lung machine. You say that the perfusionist is required to be in the operating room during the length of the procedure. You say that, per hospital protocol, it is mandatory that the surgeon, anesthesiologist, and perfusionist transport the enrollee to the unit and be there until the enrollee is in stable condition.The Plan denied your request. The Plan says the enrollee received the services in the facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to the facility. The Plan says that payment for this service is the responsibilityof the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary during an inpatient hospitalization. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.We looked at the file and Medicare rules. The services in dispute were provided during an inpatient hospitalization. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist's setup and operation of the heart-lung machine have not been met.Therefore, we decided that the Plan does not have to pay forthe perfusionist that setup and operated the heart-lung machine during the enrollee's heart surgery provided on September 12, 2019.