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

We decided that the Planhasto pay forlab services provided to the enrollee on February 5, 2020.You asked the Planto pay forthe services. You say that the claim was reported correctly.The Plandenied your request. The Plansaysthatonce a corrected claim is received, the claim will be processed according to plan benefit.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The health plan has not substantiated their denial. The plan originally agreed to pay for the services, but then denied it again on reprocessing, stating that the bill type does not match the place of treatment. The plan has not clarified exactly what bill type would be appropriate. The plan has not provided enough information to help the provider correct the claim.Therefore, we decided that the Planhas to pay forlab services provided to the enrollee on February 5, 2020.If the Plandoes 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/orsend 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: DME/ Orthotics
Decision: Unfavorable

We decided that thePlan does not have to pre-approvePower wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (E2365), Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds (K0823) and Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each (E0973).You asked the Plan to pre-approvethe power wheelchair and accessories. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says your home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided. The Plan states they will uphold the referral request and approve a new quadcane for you.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 power wheelchair and accessories. Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds (K0823) and accessories. You have a mobility limitation that impairs yourability to participate in one or more mobility-related activities of daily living (MRADLs) in customary locations in the home. The mobility limitation can be sufficiently and safely resolved by the use of an appropriately cane and manual wheelchair. The documentation does not reveal that you can safely use a power mobility device in home as the home is not accessible to powered mobility and cannot be modified for accessible egress/ingress.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 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvePower wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (E2365), Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds (K0823) and Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each (E0973).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on July 24, 2019.You asked the Planto pay forthe drug testing. You say that this was medically necessary testing.The Plandenied your request. The Plansaysthere is no evidence that this provider is actively treating the enrollee for a specific medical condition. The provider did not submit records showing that this testing was ordered by a physician involved in the enrollee's care.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plandoes not haveto payforthe presumptive and definitive drug testing provided on July 24, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on July 17, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be 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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301,80302, 80303, 80304 and G0479) HCPCS G0483:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 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 supported by the medical records. Our physician reviewer found an order form was submitted with a physician signature, but enrollee's name and detailed presumptive tests ordered were not included in this order as required to be a valid test order.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 Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telemedicine visit on April 24, 2019.
You asked the Plan to waive the copayment for a telemedicine visit. You say that you did not call for this visit
and believe the claim is fraud. The Plan denied your request. The Plan says the copayment you are being
charged is correct.
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 PCP visits received from a standard primary care physician under the Preferred Rx plan.
You have been asked to pay a $5 copayment for a telemedicine visit. A telemedicine visit falls within the
Physician/Practitioner services, including doctor's office visits 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 a telemedicine visit on April 24, 2019.
Your complaint about this visit being fraud is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on December 5, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized 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.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from February 24, 2020 through February 27, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 youwere admitted on February 24, 2020 and discharged onFebruary 27, 2020. You were asked to pay a $465 copayment per day from February 24, 2020 through February 26, 2020, days 1-3 of your inpatient hospital care. You were discharged on February 27, 2020 andthere 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 forinpatient hospital care from February 24, 2020 through February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on August 7, 2019.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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and massspectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."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 supported by the medical records. Our physician reviewer found although there is a provided order form with a signature, there is no indication this is the prescribing physician or that abnormal presumptive testing results justified the order. 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 drug testing services (HCPCS G0483) provided to the enrollee on August 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99282) provided on January
1, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration
because this claim was filed in a reasonable time. The Plan denied your request. The Plan says this claim was
received past the allowed 12-month timeframe.
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 the emergency department visit was not filed until January 10, 2020. 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 an emergency department visit (99282) provided
on January 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left L5-S3 cooled radiofrequency ablation (RFA).
You asked the Plan to pre-approve left L5-S3 cooled radiofrequency ablation (RFA). You say that the
requested left L5-S3 cooled RFA is medically necessary. The Plan denied your request. The Plan says the
requested left L5-S3 cooled RFA is not medically necessary.
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 left L5-S3 cooled radiofrequency
ablation (RFA). Our reviewer says that the requested left L5-S3 cooled RFA is not medically necessary. Our
physician reviewer found this enrollee presents with complaints of grade 7/10 left buttock pain with
intermittent radiation into the leg. Pain is reported with walking and sitting. She is status post multiple left L5-
S3 cooled radiofrequency ablation with 80% relief for 6-10 months. She has reportedly failed physical therapy
and medications. Current clinical exam findings did not document any lumbar or sacroiliac findings. Under
consideration is a request for left L5-S3 cooled radiofrequency ablation. Current evidence based medical
literature indicates that cooled radiofrequency ablation can significantly relief sacroiliac region pain, but
indicated that more high-quality and large-scale randomized controlled trials are required to validate these
findings. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of these
procedures for this enrollee as discussed above. Additionally, there are insufficient clinical findings to support
the presence of sacroiliac joint mediated pain or sacroiliitis. No imaging findings to support a diagnosis of
sacroiliitis are reported. There is no compelling rationale presented or extenuating circumstances noted to
support the medical necessity of this request at this time. Therefore, this request for left L3-S3 cooled
radiofrequency ablation is not medically reasonable and 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 left L5-S3 cooled radiofrequency ablation (RFA) have not been met. Therefore,
we decided that the Plan does not have to pre-approve left L5-S3 cooled radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on October 14, 2019.
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 documentation submitted did not include a physician order/lab requisition or medical records
stating exactly what tests are to be 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 the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service
HCPCS G0483:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to,
GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays
(e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope
or other universally recognized internal standards in all samples (e.g., to control for matrix effects,
interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or
quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including
metabolite(s) if performed
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 supported by the medical records submitted. Our physician reviewer
found a provided order form was submitted but was missing the enrollee's name but did list the definitive tests
included in the order.
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 drug testing services (HCPCS G0483) provided to the enrollee on October 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not
covered.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device.