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

We decided that the Plan does not have to pay forthe drug testing rendered on July 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says 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 forthe drug testing rendered on July 1, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 19,2020.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 the non-urgent services are not authorized because the rendering laboratory is a non-network provider that does not work with the enrollee's health 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 rendering laboratory 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 drug testing services provided to the enrollee on March 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (77080, 77067, 77063) provided on December 31, 2019.You asked the Plan to pay for the radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the radiology services (77080, 77067, 77063) provided on December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on March 19, 2020.You asked the Plan to waive the copayment for the cystoscopy. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a cystoscopy in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $325 copayment for each visit to an outpatient hospital facility for Medicare-covered services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a cystoscopy provided in an outpatient hospital facility on March 19, 2019. You have been asked to pay a $325 copayment for the cystoscopy. The cystoscopy 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 the cystoscopy provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the naturopath services rendered on April 8, 2020.
You asked the Plan to pay for these services. You say that the treatment from this provider has helped you get better. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the naturopath services rendered on April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided March 10, 2019 through March 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found this patient was sufficiently complex and had risk of exacerbation with her underlying medical
chronic problems that admission was reasonable. The fact that the patient improved to be discharged the
following day, does not mean the patient did not meet admission criteria at presentation. It was reasonable to
expect that the patient would need to spend at least two midnights with the presentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided March 10, 2019 through March 11, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea pneumatic compression device coded E0652.You asked the Plan to pre-approvea pneumatic compression device coded E0652. You say that you would like the pan to reconsider their denial.The Plan denied your request. The Plan says that the requested device is not medically necessary.of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 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 pre-approve a pneumatic compression device coded E0652. Our reviewer says that the documentation supports that the requested device is medically reasonable and necessary. Our physician reviewer found the enrollee has refractory lymphedema that does extend to the abdomen. There is sufficient documentation that his edema extended to the abdomen. It is well documented he has had extended therapy with alternative standard therapy. Therefore, the enrollee meets criteria for the requested device.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 pneumatic compression device coded E0652 have been met.Therefore, we decided that the Plan has to pre-approvea pneumatic compression device coded E0652.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 17, 2019 through November 20, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that this should be covered by the Plan 100% because you pay for parts A and B monthly.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 November 17, 2019 and discharged on November 20, 2019. You were asked to pay a $465 copayment per day from November 17, 2019 through November 19, 2019, days 1-3 of your inpatient hospital care. You were discharged on November 20, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $465 copayment per day required for days 1-4. 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 November 17, 2019 through November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system.
You asked the Plan to pre-approve a CardioMEMS system. You say that the CardioMEMS system is indicated for the enrollee's conditions. You say that the totality of the evidence and clinical studies support the clinical benefit of remote hemodynamic monitoring. You say that the CardioMEMS system is medically reasonable and necessary. The Plan denied your request. The Plan says they will only pay for the requested device when involving a clinical trial.
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 a CardioMEMS system. Our reviewer says that a CardioMEMS system is not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device should still be considered experimental or investigational. 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 CardioMEMS system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 11, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the medical records do not support the services billed.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Other than the physician lab order, there is no other specific documentation showing the need for this testing on a diagnostic basis. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the upper extremity (73221).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the documentation does not include a differential diagnosis, results of conservative therapy or associated plan of care. Without the support of the documentation, medical necessity cannot be determined.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the upper extremity (73221)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on February 4, 2020.You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received labs on the date ofservice at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $5 copayment for Medicare-covered lab services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory services on February 4, 2020. You have been asked to pay a $5 copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on March 19, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network services.
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 service at issue. We found no exception that would require the Plan to pay for these services.
Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on March
19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the x-ray provided on January 16, 2020.
You asked the Plan to waive the coinsurance for the x-ray. You say that you do not feel responsible for the copayment because the provider is out-of-network. 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 50% coinsurance for basic radiological services at a freestanding radiological facility. You have been asked to pay $21.99 which is 50% of the allowed amount for the x-ray. The allowed amount is $43.99. ($43.99 x 50% = $21.99). The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that the freestanding radiological facility is out-of-network.
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 x-ray provided on January 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71046) provided January 31, 2020.You asked the Plan to pay forthe chest x-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was not submitted with complete information.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 71046 is not supported in the medical record. Specifically, the claim submitted did not include a complete or valid diagnosis code. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71046) provided January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 9, 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 on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Superion interspinous spacer.You asked the Planto pre-approvethe spacer. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental and investigational.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 spacer. Our reviewer says that the requested spacer is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with chronic low back pain radiating into the right lower extremity with associated weakness. He had difficulty standing up straight and relief with bending forward. Functional limitations are noted in activities of daily living. Past surgical history was positive for multilevel lumbar fusion, reportedly involving all lumbar levels. There is current electrodiagnostic evidence of chronic right L4-S1 radiculopathy. There is imaging evidence of moderate to severe neuroforaminal stenosis from L2/3 through L5/S1. Detailed evidence of reasonable and/or comprehensive non-operative treatment is documented. Under consideration is a request for Superior Interspinous Spacer System at the L2/3 level. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. This injured worker has imaging evidence of moderate to severe neuroforaminal stenosis from L2/3 through L5/S1. FDA contraindications include osteoporosis and prior lumbar fusion or decompression at the index level. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this 70-year-old male. Additionally, the requesting physician reports the enrollee is status post revision L1-S1 fusion. Therefore, this request would not be considered medically reasonable and necessary for treatment of this enrollee's medical condition.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 spacer have not been met.Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CX Bladder test provided to the enrollee on March 23, 2020.
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says this test has unproven clinical utility.
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 pay for the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found several reviews have been performed to assess the myriad urine markers proposed for bladder cancer surveillance. They note that none of the markers has been proven sensitive and specific enough to replace cystoscopy. While commercially available urinary markers are promising, the clinical evidence is insufficient to warrant the substitution of the cystoscopic follow-up scheme with any of the currently available urine marker tests. The review has determined that the items/services at issue in this case are 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 test have not been met. Therefore, we decided that the Plan does not have to pay for the CX Bladder test provided to the enrollee on March 23, 2020.