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

We decided that the Plan does not have to pay for a diagnostic mammogram (77065) provided October 23, 2019.
You asked the Plan to pay for the diagnostic mammogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the diagnostic mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a diagnostic mammogram (77065) provided October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aminolevulinic acid administration provided on January 16, 2020.You asked the Plan to waive the coinsurance for the aminolevulinic acid administration. You say that you were informed you would only have a $45 copayment.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare Part B prescription drugs. You have been asked to pay $78.47, which is 20% of the allowed amount for the aminolevulinic acid administration. The allowed amount is $392.37 (20% x $392.37 = $78.47). The aminolevulinic acid administration falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for the aminolevulinic acid administration provided on January 16, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are other in-network plastic surgeons 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.You asked the Plan to pre-approve a seat lift mechanism. The Plan denied your request. The Plan says that there is no documentation that you have been diagnosed with severe arthritis of the hip or knee or severe neuromuscular disease, or that you are completely incapable of standing up from a regular armchair or any chair in your home.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 seat lift mechanism. Our reviewer says that a seat lift mechanism is not medically reasonable and necessary. There is no qualifying condition or documentation that you are unable to transition from a seated to standing position in the home. Our physician reviewer found that your condition does not meet Medicare criteria for this item.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 seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure oral nutritional formula.You asked the Plan to pre-approvethese services. You say that the formula helps control your diabetes.The Plan denied your request. The Plan says oral nutrition products are not covered.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-approveEnsure oral nutritional formula.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services in Germany for cancer treatment provided from June 24, 2019 to July 8, 2019. You asked the Plan to pay for the hospital services in Germany. You say that you went to this hospital to treat your cancer because the success rate is 95%-97% to cure cancer and the success rate in the USA is 25% to cure cancer. The Plan denied your request. The Plan says this hospital is not a Medicare provider. The Plan must follow Medicare rules. Medicare rules say that health plans must pay for emergency and urgently needed services. Medicare rules say that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan. We looked at the file and Medicare rules. The file shows that the cancer treatment at this hospital in Germany was not due to an emergency or an urgently needed service because of an unforeseen illness or condition that was not reasonable to get the services from the plan. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services in Germany for cancer treatment provided on from June 24, 2019 to July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe knee replacement provided from September 26, 2019 through October 10, 2019.You asked the Plan to waive the coinsurance for the knee replacement. You say that you weren't at the hospital until the morning of the surgery. You say that you were under the impression that you would be an inpatient.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $2,1083.83 for the knee replacement. Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityOctober 9, 2019-October 10, 2019Knee Replacement$10,544.17$2,1083.83$2,1083.83The knee replacement falls within the "Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that you were only charged for the outpatient procedure provided from October 9, 2019 through October 10, 2019.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 knee replacement provided from September 26, 2019 through October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on November 14, 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 assistant surgeon services for code 27236-AS are not covered.
The Plan must follow Medicare rules. The rules say that Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not available) is used to bill for assistant at surgery services. We looked at the file and Medicare rules. The file shows that code 27236-AS (open treatment of femoral fracture) was billed with modifier -AS; however, the records show that the assistant surgeon services were performed by a physician. The -AS modifier is not appropriate in this instance. 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 assistant surgeon services rendered on November 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on October 19, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with the charges because you did not request the ambulance yourself. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for ambulance services. You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided on October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95813 provided on August 5, 2019. You asked the Plan to pay for the EEG services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95813 is electroencephalogram (EEG) extended monitoring; greater than 1 hour. We find that CPT code 95813 is not supported in the medical record. Specifically, the technical report did not include documentation of electroencephalogram (EEG) extended monitoring for 61-119 minutes; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the EEG services have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95813 provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of closed elbow dislocation services coded 24600 provided on March 26, 2019.
You asked the Plan to pay for the treatment of closed elbow dislocation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. 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 24600 is treatment of closed elbow dislocation; without anesthesia. We find that CPT code 24600 is not supported in the medical record. Specifically, this code was billed with a diagnosis code that was mismatched to the procedure modifier on the claim line. Based on this information, we decided that Medicare rules for coverage of the treatment of closed elbow dislocation services have not been met. Therefore, we decided that the Plan does not have to pay for the treatment of closed elbow dislocation services coded 24600 provided on March 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an IRF admission.
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 enrollee does not meet criteria for coverage of an acute IRF admission. Our physician reviewer found that the enrollee is medically stable with no evidence of a need for supervision by a Physical Medicine and Rehabilitation physician or a need for acute rehabilitation nursing care. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. The IRF admission is not medically necessary based on his current functional status and medical stability. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on June 26, 2019, August 7, 2019 and September 11, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the 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 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 the physician's services provided on June 26, 2019, August 7, 2019 and September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora refraction (92015) provided on November 21, 2019.You asked the Plan to pay fora refraction. You say that you should not have to pay for this service.The Plan denied your request. The Plan says this service is only covered once a year.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one routine eye exam every 12 months.We looked at the file and the Plan's rules. The record shows that you previously had an eye exam in February 2019. This means that the Plan's frequency limitations have been exceeded.Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met.Therefore, we decided that the Plan does not have to pay fora refraction (92015) provided on November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the therapeutic lightbox provided on November 5, 2019. You asked the Plan to pay for the therapeutic lightbox. You say that your doctor ordered this as part of your treatment. The Plan denied your request. The Plan says that under Medicare guidelines a lamp is not primarily and customarily used to serve a medical purpose.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the therapeutic lightbox by a contract provider. The file does not show that the Plan provided notice that the therapeutic lightbox would not be covered. Under Medicare rules, this means the therapeutic lightbox is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the therapeutic lightbox provided on November 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73030 and CPT 73130) provided to
the enrollee on November 12, 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 denied codes remain 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 the denied codes is:
CPT 73030:
Radiologic examination, shoulder; complete, minimum.
CPT 73130:
Radiologic examination, hand; minimum of 3 views
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 the
review of the records revealed no report of any of the three exams in question and no reference by the
orthopedist to the x-ray findings. As such, the CMS guidelines require written confirmation in the form of a
report in order for reimbursement for radiographic studies to occur.
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 radiology services (CPT 73030 and CPT 73130) provided to the enrollee on November 12,
2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic services (G0463) provided on
September 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the clinic visit. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not preauthorized 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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient clinic services (G0463) provided on
September 25, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on November 29,
2019.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 71045
for the x-ray services has a bundled relationship with code 36556 and cannot be paid as billed. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on
November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the stair glide purchased on September 23, 2019.You asked the Plan to reimburse you fora stair glide. You say that the Plan approved the stair lift and you would be reimbursed80%.The Plan denied your request. The Plan says there are no calls noted in regards to the stair lift and there is no authorization.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to reimburse you for the stair glide purchased on September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injection.
You asked the Plan to pre-approve Zilretta injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Zilretta injection. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found you have a history of osteoarthritis of the right knee. The records indicate that you received a right knee intra-articular injection of Zilretta (Triamcinolone ER injection) in December 2019. Per the FDA approved prescribing information, Zilretta is indicated for the management of knee pain due to osteoarthritis and is not intended for repeat administration and can only be used once per knee per lifetime. Therefore, you do not meet criteria for the requested injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta injection.