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

We decided that the Plan does not have to pay for an electrocardiogram (93000) provided October 21, 2019.
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the payment for this service is included in a Part A DRG inpatient payment.
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 93000 is not supported in the medical record. Specifically, payment for this service is included in the facility DRG/PPS payment. Separate payment cannot be rendered. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93000) provided October 21, 2019.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay foroutpatient psychotherapy services provided by a contracted mental health counselor on April 16, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says that multiple attempts have been made to get information from the provider's office, such as documentation of current symptoms, findings on exam, or previous treatment.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.The services were provided by a counselor who is a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan.Therefore, we decided that the Plan has to pay foroutpatient psychotherapy services provided a contracted mental health counselor on April 16, 2020.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 usthe new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an out of network (OON) provider. You asked the Plan to pay for the office visit (99215). You say that you would like reconsideration because the services were medically necessary. The Plan denied your request. The Plan says the member does not have out-of-network benefits unless prior authorization is granted.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 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 medical services provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on January 31, 2020.
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 has a status code of I, which indicates the code is not covered.
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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran office visit provided on December 16, 2019.You asked the Plan to waive the deductible foroffice visit. You say that this was a regular office visit with no testing or procedures done, so you feel that the billed amount is outrageous.The Plan denied your request. The Plan says the deductible amount you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $185 deductible for primary care office visit. At this time this claim was processed, $0 of the $185 deductible had been met. The allowed amount of the service is $171.13, resulting in a deductible obligation of $171.13.The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $185 deductible for Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time office visit was received on December 16, 2019.Therefore, we decided that the Plan doesnot have to waive the deductible foran office visit provided on December 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on January 23, 2020.You asked the Plan to waive the copay forthe ambulance transport. You say that you would like your charges reduced.The Plan denied your request. The Plan says that the claim processed according to your Evidence of Coverage.The rules say a plan must disclose to its enrollees in clear, accurate termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 copay for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $310 copay for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 copay forthe ambulance transport provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 28, 2020 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that themember's primary care physician did not refer these 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 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 physician services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cetuximab.
You asked the Plan to pre-approve Cetuximab. You say that the drug is medically necessary. The Plan denied your request. The Plan says Cetuximab is not approved for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Cetuximab. Our reviewer says that Cetuximab is not medically necessary. Our physician reviewer found the enrollee is noted to have metastatic esophageal cancer. Cetuximab is labeled to treat head & neck cancer and colorectal cancer. Additionally, cetuximab has an off-label indication to treat NSCLC. Consequently, the enrollee does not have a medically accepted indication for the use of cetuximab. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cetuximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Cetuximab.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary for several upcoming procedures. The Plan denied your request. The Plan says more than twelve trips cannot be covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on February 10, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because your primary care provider was not available.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 $45 copayment for each specialist visit. You have been asked to pay a $45 copayment for a specialist visit. A specialist 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 fora specialist visit provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on October 28, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve the requested service. You say that the enrollee has had previous epidural steroid injections with relief. The Plan denied your request. The Plan says the enrollee has not had documented success of at least a 50% at 2 months post procedure.
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 requested service Our physician reviewer found that the enrollee has low back pain and right sacroiliitis. A sacroiliac joint injection was administered on July 16, 2020. The enrollee is scheduled for a second sacroiliac joint injection on July 30, 2020. Coverage for the requested procedure, less than 2 months after prior sacroiliac joint injection for pain due to sacroiliitis is not medically 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 the requested service have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, and Pemetrexed.You asked the Plan to pre-approve Carboplatin, Pembrolizumab, and Pemetrexed. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drugs are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Carboplatin, Pembrolizumab, and Pemetrexed. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic Non-small-cell lung carcinoma (NSCLC). The enrollee was initially treated with Paclitaxel and Carboplatin. The requested use of Carboplatin, Pembrolizumab, and Pemetrexed is not FDA-approved for the enrollee's diagnosis. The use of the drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drugs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Pembrolizumab, and Pemetrexed have not been met.Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, and Pemetrexed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature and attendant control for a power wheelchair (PWC).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the items are not covered.The Plan must follow Medicare rules. The rules say that a power seat elevation feature is non-covered and an attendant control is non-covered if provided in addition to a beneficiary-operated drive control system.We looked at the file and Medicare rules. The requested power seat elevation feature is non-covered by Medicare. The file shows that a beneficiary-operated drive control system is included in the approved accessories for the PWC; therefore, the attendant control is non-covered. Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature and attendant control for a power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a portable oxygen system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 for a portable oxygen system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay forintermittent urinary catheters (A4351x600) provided on April 15, 2019.You asked the Plan to pay forthe intermittent urinary catheters. You say that you would like reconsideration because the billed supplies are medically necessary.The Plan denied your request. The Plan says the submitted records consist of conflicting documentation regarding the units billed.The Plan must follow Medicare rules. Medicare rules say that when billing more than one month's supply of these items, include a narrative in the NTE segment of the electronic claim indicating the number of months you are billing.We find that CPT code A4351x600 is not supported in the record. Specifically, the physician order indicates that 200 units are to be supplied per month. The record shows that 600 units were delivered for this date of service. There is no indication in the record to suggest that more than one month of supplies has been billed. Based on this information, we decided that Medicare rules for coverage of the intermittent urinary catheters have not been met.Therefore, we decided that the Plan does not have to pay for intermittent urinary catheters (A4351x600) provided on April 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient;first 30-74 minutes (99291) provided April 4, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.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 99291 is not supported in the medical record. Specifically, the medical records did not contain a critical care note of 30-74 minutes for date of service April 4, 2019. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided April 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided to the enrollee on March 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use CPT code 81479. We looked at the file and Medicare rules. The services in question were billed with several CPT codes. Per the LCA, the services in question should have been billed with CPT 81479. 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 the genetic testing services provided to the enrollee on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 30, 2019 through January 3, 2020.You asked the Plan to waive the copayment for inpatient hospital care. You say that the therapy you received does not amount to the charges billed while inpatient.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 December 30, 2019 and discharged on January 3,2020. You were asked to pay a $360 copayment per day from December 30, 2019 through January 2, 2020, days 1-4 of your inpatient hospital care. You were discharged on January 3, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $360 copayment per day required for days 1-5. 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 December 30, 2019 through January 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 6,
2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you have never had to pay a
copayment in the past due to polyps. 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 $150
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
The medical records show that you received a diagnostic colonoscopy due to polyp removal and a history of
diarrhea on January 6, 2020. Therefore, you are responsible to pay the $150 copayment.
You have been asked to pay a $150 copayment for a colonoscopy. A colonoscopy 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 for a colonoscopy provided on January 6, 2020.