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

We decided that the Plan does not have to pay for outpatient hospital debridement of wounds provided on
June 6, 2019.
You asked the Plan to pay for the outpatient hospital debridement of wounds. 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 outpatient hospital debridement of wounds provided on
June 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram rendered on September 20, 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 procedure code 77067 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 77067 is screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. We find that CPT code 77067 is not supported in the medical record. Specifically, the records do not show that two views of each breast were obtained. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammogram rendered on September 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdomen x-ray rendered on October 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
The provider submitted a claim for procedure code 74018 (abdomen x-ray, one view) under claim number
820192870623759. The Plan previously paid for this code for the date of service at issue under claim number
820192870623756. Therefore, we decided that the Plan does not have to pay for the abdomen x-ray rendered on October 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90792) provided on August 28, 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 there are in-network providers that could have provided these services. The services were not emergent or preauthorized.
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 the Plan does not have to pay for the outpatient mental health services (90792) provided August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1mg Capsules.
You asked the Plan to pre-approve Vascepa. You say that the drug is medically necessary. The Plan denied
your request. The Plan says this type of self-administered drug is not eligible for coverage under the Part B
medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa 1mg Capsules.
Benefits for Vascepa may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a bypass graft, other than vein (35656).
You asked the Plan to pre-approve a bypass graft, other than vein. You say that the services are necessary. The
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not
been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a bypass graft, other than vein. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has significant claudication and ABIs consistent with peripheral
artery disease (PAD). She is unable to participate in an exercise program. The requested procedure is medically
necessary and reasonable.
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 bypass graft, other than vein have been met. Therefore, we decided that the
Plan has to pre-approve a bypass graft, other than vein (35656).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on April 24, 2018.
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 claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until October 30, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on April 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical cancer screening rendered to you on October 2,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says you exceeded the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that a cervical cancer screening is covered once every
24 months.
We looked at the file and Medicare rules. The file shows that you previously had a cervical cancer screening on
March 1, 2019 for which the Plan approved and paid. The cervical cancer screening on October 2, 2019 was
performed fewer than 24 months from your previously covered screening. Therefore, we decided that the Plan
does not have to pay for the cervical cancer screening rendered to you on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on August 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that the member had a fractured ankle. You say that this x-ray was necessary to confirm how the fracture was healing. The Plan denied your request. The Plan says no prior authorization was obtained for this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an x-ray provided on August 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an IV infusion (96368) provided on September 18, 2019.
You asked the Plan to pay for the IV infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate that intravenous infusion, for therapy, prophylaxis, or diagnosis; concurrent infusion was performed.
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 96368 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the IV infusion. Our reviewer says that the billing of CPT 96368 is not supported. Our reviewer found the documentation shows that Benadryl and Decadron were administered at the same time, but that the two drugs were mixed into one 50ml bag of normal saline for administration. Furthermore, the amount of time to administer these drugs was 10 minutes. As such, these drugs were not given concurrently and are not considered an infusion. 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 IV infusion have not been met. Therefore, we decided that the Plan does not have to pay for an IV infusion (96368) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee orthosis (L1851-LT), a left suspension sleeve (L2397-LT), a left ankle foot orthosis (L1971-LT), and a lumbar-sacral orthosis (L0650) provided to the enrollee on September 26, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitutes for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an 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. As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the enrollee, at the originating site. We looked at the file and Medicare rules. In this instance, the records do not show that the enrollee was present at an originating site located in a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or a country outside of an MSA served by the telehealth network. Additionally, the record does not show that the encounter was conducted using an audio
and video telecommunication system. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for a left knee orthosis (L1851-LT), a left suspension sleeve (L2397-LT), a left ankle foot orthosis (L1971-LT), and a lumbar-sacral orthosis (L0650) provided to the enrollee on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on July 1, 2019.
You asked the Plan to pay for CPT code 99190. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The plan states payment for these services is the responsibility of the facility.
The Plan must follow Medicare rules. 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. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on July 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit, 60 minutes (90837) provided on August 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy visit, 60 minutes. You say that you have been seeing this doctor for a number of years and do not want to switch to another provider. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers require prior authorization, therefore coverage criteria has not been met.
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 a psychotherapy visit, 60 minutes (90837) provided on August 23, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered to you on September 5, 2019.
You asked the Plan to waive the copayment for these services. You say that the services should have no copayment because they were related to a wellness visit. The Plan denied your request. The Plan says the copayment 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 $10 copayment for each Medicare-covered laboratory test.
Review of the file shows that you received lab services on September 5, 2019. These services are not part of an annual wellness visit. You have been asked to pay a $10 copayment for these services. These services fall within the Medicare-covered laboratory test benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered to you on September 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a revision of a total hip arthroplasty (27134) provided on June 10, 2019.
You asked the Plan to pay for the revision of a total hip arthroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 27134-LT is not supported by the medical records submitted.
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 27134 is revision of total hip arthroplasty; both components, with or without autograft or allograft. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the revision of a total hip arthroplasty. Our reviewer says that the documentation does not support the services as billed. Our reviewer found only the acetabular liner was exchanged, not the entire acetabular component. As such, both components (acetabular component, femoral stem) were not revised.
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 revision of a total hip arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for a revision of a total hip arthroplasty (27134) provided on June 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the transesophageal echocardiogram (TEE) rendered to the enrollee on April 10, 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 procedure code 93313 was billed with an inappropriate modifier.
The Plan must follow Medicare rules. The rules say that modifiers 26 & TC cannot be used with codes with a PC/TC indicator of 0. The provider submitted a claim for procedure code 93313 (TEE) with modifier -26. This code has a PC/TC indicator of 0 and cannot be billed with modifier -26. Therefore, we decided that the Plan does not have to pay for the transesophageal echocardiogram (TEE) rendered to the enrollee on April 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
September 22, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you need help pay with
the bill. You say it is very hard for you to keep up with all of the bills. 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 $90
copayment for each emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency Care" benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
emergency room visit provided on September 22, 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 October 25, 2018 to October 26, 2018. You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically 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 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 medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was observation level. She had stable vital signs and symptoms had improved. She was ordered the remained of her bowel preparation and underwent anticipated procedures the following morning. She remained stable and was discharged the following day. Inpatient services were not supported by the documentation. 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 October 25, 2018 to October 26, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on July 31, 2019 from an out-of-network
provider.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says you exhausted your benefit allowance.
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. Although you purchased the Phonak CROS system as a set, the plan
reimbursed you for each device according to the applicable benefit: The plan paid $500.00 benefit maximum
for the Hearing aid (Phonak Audeo B90-R). You will not be reimbursed for any amount that exceeds this
maximum. There is a $150.00 plan deductible for Medicare-covered hearing service. The plan paid an
additional $1,350.00 for the V5181- receiver (Phonak CROS B-R), after applying a $150.00 plan deductible.
You are responsible for the remainder of the cost. Therefore, we decided that the Plan does not have to pay for
the hearing aids purchased on July 31, 2019 from an out-of-network provider.