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

We decided that the Plan has to pre-approve CT scan of the head and brain for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says that there are no signs or symptoms of metastatic disease involving the brain.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found it is not reasonable to assume that neurologic symptoms are necessary when metastatic foci within the brain are small and perhaps located in relatively silent areas of the brain. This enrollee is 84 years old and cannot tolerate MRI so contrast enhanced CT of the brain is the next best test to evaluate for occult metastasis. The enrollee is due for CT of the chest, abdomen and pelvis at this time and the requested CT of the brain can be obtained with the same single contrast injection at the same sitting. This procedure is in the best interest of the enrollee and fits with the oncologist's treatment plan for surveillance. If positive, the treatment plan will obviously change.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 scan have been met.Therefore, we decided that the Plan has to pre-approve CT scan of the head and brain for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the
documentation does not support the need for skilled nursing or therapy services on a daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF services. Our physician reviewer
found that from a nursing perspective, you have stable vital signs, your lungs were clear, and you were treated
for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are
at a standby to minimal assist level with function mobility. Although there are identifiable skilled therapy
service needs, you do not require skilled nursing or therapy services on a daily basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you were supposed to receive four
packages of Kotex and one package of dual pads. You say that you need more. You say that you have been
having to buy them out of pocket for three months. The Plan denied your request. The Plan says incontinent
pads are non-reusable supplies and hygienic items are not covered.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional level of radiofrequency ablation (64636 x2).
You asked the Plan to pre-approve an additional level of radiofrequency ablation (64636 x2). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 6 joints would exceed the allowable limit for this service.
The Plan must follow Medicare rules. Medicare rules say that no more than 4 joints are allowed to be injected per session. We looked at the file and Medicare rules. The original request was for 6 joints to be injected. Medicare covers no more than 2 thermal radiofrequency sessions in any 12-month period, involving no more than 4 joints per session, e.g., 2 bilateral levels or 4 unilateral levels. In this case, the Plan approved 4 joints, which is the allowed amount per session. Therefore, we decided that the Plan does not have to pre-approve an additional level of radiofrequency ablation (64636 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient stay provided from August 20, 2018 through August 21, 2018 and physical therapy provided from September 5, 2018 through September 27, 2018.You asked the Plan to waive the cost share for the inpatient stay and physical therapy. You say that you were not informed the services or the hospital was out-of-network. You say that the bills are a hardship.The Plan denied your request. The Plan says the cost share 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 40% coinsurance for each Medicare-covered out-of-network hospital stay and a $70 copayment for each Medicare-covered out-of-network physical therapy and speech-language therapy visit.You have been asked to pay $5,514.91, which is 40% of the allowed amount for the inpatient stay. The allowed amount is$13,787.27 (40% x $13,787.27 = $5,514.91). You have also been asked to pay a total of $840 for physical therapy. ($70/visit x 12 visits = $840). The total amount you owe is $6,354.91 ($5,514.91+ $840 = $6,354.91). The inpatient stay falls within the "Inpatient Hospital Care" benefit category. The physical therapy falls within the "Outpatient Rehabilitation Services" benefit category The records show that the provider 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 cost share for the inpatient stay provided from August 20, 2018 through August 21, 2018 and physical therapy provided from September 5, 2018 through September 27, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on October 16, 2019.You asked the Plan to waive the copayment for cataract surgery. You say that the facility is an outpatient surgery center. You say that the copayment is inappropriate.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for in-network, Medicare-covered outpatient hospital surgery services. You have been asked to pay a $400 copayment for cataract surgery. Cataract surgery falls within the "Outpatient surgery, provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the cataract surgery was billed by the hospital. 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 cataract surgery provided on October 16, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 15, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says 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 April 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95937) provided on September 5, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation indicates train of four monitoring was performed which does not meet the CMS guidelines of CPT code 95937.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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the record. Specifically, the record indicates CPT code 95937 was billed to represent train of four monitoring. Train of four monitoringdoes not meet the CMS guidelines or definition of CPT code 95937. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95937) provided on September 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says there was no paid facility claim on file or any referral from a contracted provider.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 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 subsequent nursing facility care provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 22, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid 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 the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea percutaneous kyphoplasty for vertebral augmentation.You asked the Plan to pre-approvethe kyphoplasty. You say that it is felt that surgical intervention is needed to manage the enrollee's condition.The Plan denied your request. The Plan says the LCD criteria are not met since the fractures are more than six weeks old and routine oral analgesics have not been tried.The Plan follows Medicare rules. Medicare rules say that vertebral augmentation with kyphoplasty is covered for the treatment of compression fractures that are no more than six weeks old when standard non-surgical management has failed. 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 kyphoplasty. Our reviewer says that the requested kyphoplasty is not considered medically reasonable and necessary. Our physician reviewer found conservative measures for treating the compression fracture were not tried. This means that kyphoplasty would be experimental for this patient.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 kyphoplasty have not been met.Therefore, we decided that the Plan does not have to pre-approvea percutaneous kyphoplasty for vertebral augmentation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on August 29, 2019 by an out of network (OON) provider.You asked the Plan to pay forpathology services. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained for 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 forpathology services provided on August 29, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthotics to be provided by an out of network provider.You asked the Plan to pre-approve orthotics from an out of network provider. You say that you do not like network provider.The Plan denied your request. The Plan says there is no medical necessity for using an out of network provider.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 the orthotics to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided on April 24, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is a packaged service and no separate payment will be made.The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99100 is not supported in the record. Specifically, per Medicare, CPT code 99100 is a bundled code and no separate payment will be made. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.  Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on April 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for amputation (26951), wound closure (13160) and the application of a splint (29125) provided on February 25, 2019.You asked the Plan to pay for the amputation, wound closure and the application of a splint.You say that the services provided by the physician assistant were medically necessary and when a resident surgeon is unavailable, the physician assistant must assist with the surgery. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon or surgical team are not covered for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 26951-AS, 13160-AS and 29125-AS. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the amputation, wound closure and the application of a splint have not been met. Therefore, we decided that the Plan does not have to pay for amputation (26951), wound closure (13160) and the application of a splint (29125) provided on February 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 13, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the transport was a requirement for your wellbeing. You say that the ambulance company should be paid. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Medicare-covered one-way ground ambulance. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport 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 the ambulance transport provided on August 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on September 26, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that if you weren't taken off your medications you would not have needed the emergency transport.The Plan denied your request. The Plan says that the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per ambulance trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the ambulance trip benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the Abdomen, 2 views (74019) provided June 22, 2019.
You asked the Plan to pay for the x-ray. You say that multiple services were performed on the same day. The Plan denied your request. The Plan says the claim submitted was a duplicate.
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 74019 is not supported in the medical record. Specifically, the claim was submitted without a modifier to indicate a repeat service. Therefore, the claim submitted was duplicative of a prior claim. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an X-ray of the Abdomen, 2 views (74019) provided June 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultraviolet light therapy system (E0691) provided to the enrollee on June 17, 2017.You asked the Plan to pay forthe ultraviolet light therapy system. You say that the claim should be paid.The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been met.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 foran ultraviolet light therapy system (E0691) provided to the enrollee on June 17, 2017