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

We decided that the Plan does not have to pay for plastic surgery (CPT 11471) services provided to the enrollee on February 21, 2018.
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 Current Procedural Terminology (CPT) code 11471 remains 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 11471 is "Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found while the documentation indicates that a layered closure was performed, it does not indicate that a complex closure was performed. There is no evidence of significant wound contamination, a need for scar revision, extensive debridement, undermining, stent placement or use of retention sutures. Therefore, the billing of CPT 11471 is not supported. 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 pay for plastic surgery (CPT 11471) services provided to the enrollee on February 21, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle.
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical notes submitted for review do not document any significant impairments in one or more of the enrollee's in home MRADLs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 vehicle. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found the clinical notes submitted for review do not document any significant impairments in one or more of the enrollee's in home mobility-related activities of daily living. There is no documentation of limitations of strength that would make it difficult to use a manual wheelchair. The requested device is to be utilized for community ambulation and not to aid with your mobility-related activities of daily living. You are requesting an electrical scooter for his outdoor mobility and activities. 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 vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 1, 2019 to March 28, 2019.You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 1, 2019 to March 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse forthe cost of the visit you had on November 19, 2019.You asked the Plan to reimburse forthe visit. You say that you should be reimbursed the full amount.The Plan denied your request. The Plan says you are being reimbursed the Medicare allowed 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 $20 copayment for each specialist visit. Review of the file shows that you had an out-of-network office visit on November 19, 2019. You have been asked to pay a $20 copayment for the visit. The visit falls within the physician 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. Please note that we does not have jurisdiction over payment disputes, and you should contact the provider for reimbursement of the balance in excess of the Medicare allowed amount.Therefore, we decided that the Plan does not have to reimburse forthe cost of the visit you had on November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (70146) provided on September 24, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration as this exam was medically necessary. The Plan denied your request. The Plan says chest radiography should not be used to screen for lung cancer as it does not reduce mortality.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a chest x-ray (70146) provided on September 24, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve and in-network exception for out-of-network services and medical nutrition therapy.You asked the Plan to pre-approve the referral and medical nutrition therapy services. You say that you would like the out-of-network specialist copay to be reduced to the in-network rate due to your complex medical conditions.The Plan denied your request. The Plan says you can use your out-of-network benefits for care from this provider and you do not have a covered indication for medical nutrition therapy services.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pre-approve and in-network exception for out-of-network services and medical nutrition therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided on October 30, 2019.
You asked the Plan to waive the copayment for an observation stay. You say that you 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 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 $265 copayment for observation services. The medical records show that you had an observation stay on October 30, 2019. Therefore, you are responsible to pay the $265 copayment. You have been asked to pay a $265 copayment for an observation stay. An observation stay falls within the outpatient hospital 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 copayment for an observation stay provided on October 30, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.You asked the Plan to pre-approve Brovana. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy requirements have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Brovana. Our reviewer says that the criteria for coverage of Brovana have not been met. Our physician reviewer found the Plan requires a trial of Perforomist (formoterol) before they will approve the requested drug. The documentation does not support that the enrolle has tried Perforomist or that this drug would likely be less effective or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met.Therefore, we decided that the Plan does not have to pre-approveBrovana.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on October 22, 2019.You asked the Plan to waive the coinsurance forthe Euflexxa injection. You say that you were advised you would not have a copayment for the injections. You say that you would not have had the injections if you knew you had to pay.The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for Part B covered prescription drugs. You have been asked to pay $203.75, which is 20% of the allowed amount for the Euflexxa injection. The allowed amount is $1,018.76 (20% x $1,018.76 = $203.75). The Euflexxa injection 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 Euflexxa injection provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found you qualify for a yearly low dose lung CT based upon her age, smoking history and number of pack years. However, the followup for a so called spot on her lung is not documented in the submitted records. No report of the prior scan was included. Without knowledge of that report it is impossible to determine the timing necessary for her annual exam. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing services provided on June 19, 2019.
You asked the Plan to pay for the neuromuscular junction testing services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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. We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation indicates that train of four testing/monitoring was performed. It is inappropriate to bill the code for neuromuscular junction testing for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing services provided on June 19, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 30, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the psychotherapy services. 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 psychotherapy services provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Superion Indirect Decompression system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of evidence to supportthat these devices are as safe and effective as the gold standard of decompression.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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no head to head trials of spinal decompression surgery, the gold standard of therapy versus this device. It is still considered experimental/ investigationalThe patient is not enrolled in a clinical trial. Therefore, the request is deemed not medically reasonable or 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 system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Superion Indirect Decompression system for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forCT scan provided on October 18, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that you had a screening for lung cancer with low dose computed tomography (LDCT) and that servicehas no coinsurance, copayment, or deductible. You say you should not owe a copayment. 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 $225 copayment for in-network Medicare-covered diagnostic services such as MRI, CT scan, PET scan, nuclear cardiology studies and virtual colonoscopy. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows a CT chest without contrast was ordered and was the service provided.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 forthe CT scan provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services you provided on September 27, 2019.
You asked the Plan to pay for 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 physician's services. 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 you provided on September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided on October 22, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated(D7210) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided on October 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 units of CPT 97112 for November 18-19, 2019, November 21, 2019, and November 25-26, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation does not support the number of units billed. The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services Our reviewer says that the records provided do not support the billing of 3 units of CPT code 97112 for the dates of service in question. Our coding reviewer found that the medical records provided do not include sufficient information to corroborate that 3 units of CPT 97112 were performed on November 18, 2019, November 19, 2019, November 21, 2019, November 25, 2019 and November 26, 2019, therefore this service cannot be verified. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for 3 units of CPT 97112 for November 18-19, 2019, November 21, 2019, and November 25-26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on November 13, 2019.You asked the Plan to waive the copayment for an office visit. You say that there should be no copayment for an annual exam. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a$25 copayment for physician/practitioner/in-network. The enrollee has been asked to pay a $25 copayment for an office visit. The Plan says that a one-time exception to process this office visit as in-network. Please contact the plan for any further questions. An office visit falls within the physician/practitioner/in-network benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on November 13, 2019.