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

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 22, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that you were told this was a screening colonoscopy. 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 $250 copayment for outpatient procedures and services, including, but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within "Outpatient hospital services" benefit category. The record shows you were billed for the endoscopy and not for the colonoscopy.
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 endoscopy provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to the enrollee on
October 15, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered to the enrollee
on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital service provided to the enrollee from December 22, 2018 to December 28, 2018.
You asked the Plan to pay for the inpatient services. You say that the enrollee presented with a long list of complex acute and chronic conditions. The Plan denied your request. The Plan says that there was no authorization for the inpatient admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient services. Our physician reviewer found that the enrollee has a history of COPD on 3 liters of oxygen, lung cancer - status post lobectomy, and subarachnoid hemorrhage. She presented to a non-plan emergency room on December 22, 2018, with weakness and left sided chest pain. She had been evaluated in the ED 2 days prior and was treated for bronchitis. The evaluation revealed probable pneumonia and elevated cardio biomarkers ( troponin). She was treated with fluids and IV antibiotics. She was evaluated by Cardiology and was felt to have had a NSTEMI. She was treated and her condition stabilized and improved. She was discharged home when considered medically stable on December 28, 2018. The review has determined that the post-stabilization care services were medically necessary and reasonable. The treating physician did document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital service provided from December 22, 2018 to December 28, 2018.
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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for spontaneous bacterial peritonitis. The enrollee has completed a course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a lower level of care. The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute 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 physician reviewer found that the enrollee was admitted to the acute hospital for treatment of septic shock secondary to necrotizing fasciitis. the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays, 4 images, (D0274) provided on November 14, 2019.
You asked the Plan to pay for the dental service. You say that you had an abscess. You say that the dentist took an x-ray and gave you a prescription. You also say that you went for your annual exam and were given a full mouth x-ray. The Plan denied your request. The Plan says bitewing x-rays are covered once every 12 months. The Plan says that the frequency limit has been exceeded.
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 frequency limit for bitewing x-rays has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on January 23, 2019. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays, 4 images, (D0274) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95910, 95886, and 95999 provided on May 14, 2019.You asked the Plan to pay for CPT codes 95910, 95886, and 95999 provided on May 14, 2019. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.In this case, the CPT Code Manual definition of code 95910 is Nerve conduction studies; 7-8 studies. 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 CPT code 95910 provided on May 14, 2019. Our reviewer says that the medical records do not support the billing of CPT 95910. Our physician reviewer found the records provided for review donot support that nerve conduction testing was performed. While there was mention of pedicle screw testing, this service is otherwise considered to be a component of the EMG monitoring that was being performed during the surgery. Nor did the notes providedfor review support that all of the parameters required (per AANEM guidelines for NCS) were reported. For these reasons the CPT code in question can be said to have been incorrectly coded. We looked at this physician's review, the file, and 
Medicare rules.Based on this information, we decided that Medicare rules for coverage of CPT code 95910 have not been met.Medicare rules say that CPT code 95886 is a Type 1 add-on code and must be reported with CPT codes 95907-95913. In this case, CPT code 95886 was billed without an appropriate primary code per Medicare guidelines as CPT code 95910 is not supported in the medical records provided. Based on this information, we decided that Medicare rules for coverage of CPT code 95886 have not been met.The CPT Code Manual definition of code 95999 is Unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met.Therefore, we decided that the Plan does not have to pay forCPT codes 95910, 95886, and 95999 provided on May 14, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on
November 14, 2019.
You asked the Plan to pay for the therapeutic parenteral drug. You say that there is no charge amount on the
paperwork for this service. The Plan denied your request. The Plan says this service is not a covered benefit.
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. Therefore, we decided that the Plan does not have to pay for the
therapeutic parenteral drug (D9610) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve EpiFix (Q4186).
You asked the Plan to pre-approve EpiFix. You say that the service is necessary for the wound to heal faster. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 EpiFix. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of skin cancer. The enrollee had a lesion on his leg, which was surgically removed/biopsied in February. There is no evidence that the post-operative wound has been treated with, and failed to respond to, standard wound care measures. As such, the requested EpiFix is not shown to be currently 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 EpiFix have not been met. Therefore, we decided that the Plan does not have to pre-approve EpiFix (Q4186).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on September 25, 2019.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says Original Medicare is responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on September 27, 2019.You asked the Plan to waive the copayment for the arthrocentesis. You say that this was part of the MRI. You say that you shouldn't be responsible for the copayment.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 $290 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay $265.95, which is less than the standard $290 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe arthrocentesis provided on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit or the laboratory work provided on November 1, 2019.
You asked the Plan to waive the copayments for the specialist office visit and the laboratory work. You say that you were under the impression that if you had a procedure done, the doctor would waive the 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 $50 copayment for each Medicare-covered visit with an in-network specialist and a $35 copayment per day, per provider for Medicare-covered in-network labs. You have been asked to pay a $50 copayment for the specialist office visit and a $35 copayment for the laboratory work. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 copayments for the specialist office visit or the laboratory work provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the office visit (99211) provided by out of network (OON) provider, from May 8, 2019 to May 21, 2019.
You asked the Plan to pay for these services. You say that you have been receiving acupuncture treatment for the last fifteen years from this provider, that has been covered by the health plan. The Plan denied your request. The Plan says the acupuncture treatment was provided by an out of network provider without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the office visit (99211) provided by the out of network (OON) provider from May 8, 2019 to May 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on October 3, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the scooter purchased from SpinLife.com on September 17, 2019.You asked the Plan to reimburse you forthe scooter. You say that you purchased the scooter at the right price.The Plan denied your request. The Plan says the supplier is not certified by Medicare.The Plan must follow Medicare rules.  The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare.Therefore, we decided that the Plan does not have to reimburse you forthe scooter purchased from SpinLife.com on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 months' supply of Ensure high protein (B4150)You asked the Plan to pre-approveEnsure high protein. You say that you are appealing the denial because your doctor prescribed this for you due to having chronic anemia.The Plan denied your request. The Plan says this item is not covered under Medicare or the plan.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approve6 months' supply of Ensure high protein (B4150)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on October 18, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that you should not be responsible for the copayment because this was a part of your annual wellness visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say aplan 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 $35 copayment per day, per provider, for in-network Medicare-covered lab services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $35 copayment for the laboratory work.You have been asked to pay a $27.28 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is considered a separate service.This means that you have been asked to pay the correc tamount 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 work provided on October 18, 2019.