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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 15, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with how the claim
was processed. The Plan denied your request. The Plan says the claims were processed correctly, and the
enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $35 copayment for each specialist visit.
The enrollee has been asked to pay the allowed amount of $24.10, which is less than the $35 copayment for a
specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on
July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered from August 19, 2019 to September 20, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in the home setting and should have been billed with POScode 12.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered from August 19, 2019 to September 20, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF services provided from July 1, 2020, to July 31, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you feel that no one properly addressed your condition that resulted from your fall. The Plan denied your request. The Plan says that the copayment 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 per day for days 1 to 20 of a benefit period, and $60 per day for days 21 to 44 of a benefit period, and $0 per day for days 45 to 100 of a benefit period for SNF care. This SNF stay lasted 31 days, which were days 13 to 43 of the SNF benefit period, resulting in a total copayment amount of $1,540. You have been asked to pay $20 per day for days 1 to 20, $60 per day for days 21 to 44, and $0 per day for days 45 to 100 of a benefit period for the SNF services. the SNF services falls within the SNF care 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 SNF services provided from July 1, 2020, to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment of vein.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the information received shows that the member's vein is 2.3 mm below the knee and
2.6 mm at the mid knee in the area that would be treated.
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 services. Our physician reviewer
found based on the records the patient had venous diameter less than 3mm in the left lower extremity so that
location would not meet coverage criteria for endovascular ablation that requires both reflux duration greater
than 500 msec and vein diameter of greater than 3mm. In this location coverage criteria are not met.
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 pre-approve treatment of vein.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarterial catheterization provided on January 16, 2020.You asked the Plan to pay forarterial catheterization. You say that the Plan should pay this claim.The Plan denied your request. The Plan says this code should not be billed by an anesthesia practitioner.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 33210 is Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure.)We find that CPT code 33210 should not be billed by an anesthesia practitioner.Based on this information, we decided that Medicare rules for coverage of arterial catheterization have not been met.Therefore, we decided that the Plan does not have to pay forarterial catheterization provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

e decided that the Plan does not have to pay forout of network lab services provided to the enrollee on November 20, 2019.You asked the Plan to pay forthese services. You say that this claim should be paid.The Plan denied your request. The Plan says these services were ordered by a non-plan provider and the enrollee did not have prior authorization for out of network services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 forout of network lab services provided to the enrollee on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordurable medical equipment and supplies received from April 10, 2020, to July 9, 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 the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies.The Plan must follow Medicare rules. Medicare rules say that DME supplies must be provided with a proof of delivery. 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:HCPCS E0607:Home blood glucose monitorHCPCS A4253:Blood glucose test or reagent strips for home blood glucose monitor, per 50 stripsHCPCS A4256:Normal, low, and high calibrator solution/chips
HCPCS A4258:Spring-powered device for lancet, eachHCPCS A4259:Lancets, per box of 100We asked our coding 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 coding reviewer found the documentation submitted was reviewed, and it does not meet the criteria. The documentation an itemized proof of delivery. The documentation includes shipment through FedEx; however, there is no documentation of the DME being sent to the enrollee.We looked at this coder's review, the file, and Medicare rules. The required documentation pertaining to the proof of delivery of these supplies was not provided. 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 fordurable medical equipment and supplies received fromApril 10, 2020, to July 9, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean electronic connection, expandable controller, and harness for a power wheelchair for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that itemsand 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's upper extremity strength and function are sufficient for the enrollee to control any power options through their own individual switches. The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control.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 notbeen met.Therefore, we decided that the Plandoes not haveto pre-approvean electronic connection, expandable controller, and harness for a power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services (CPT 99499) provided to the enrollee on January 19, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires a narrative explanation of unlisted CPT codes on the claim or attached to the claim.
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 99499 is [*****enter CPT Codebook definition*****]. 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 documentation submitted was reviewed, and does not meet the criteria. Documentation is required to report CPT 99499. Per CMS IOM, Publication 110-04, Medicare Claims Processing Manuel Chapter 12 Sections 30.6.1and 30.6.8. "In what should be a rare circumstance when the provider concludes only CPT 99499 is appropriate, it is the responsibility of the provider to ensure all necessary information has been documented in the medical record. The service must meet medical necessity and reasonableness standards. Documentation must include the place of service and a brief statement why another E/M code does not apply".
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 evaluation and management services (CPT 99499) provided to the enrollee on January 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on May 21, 2020.
You asked the Plan to waive the coinsurance for DME. You say that you paid less in the past and disagree with
the increase in charges. 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 20%
coinsurance for DME and related supplies.
You received DME on May 21, 2002. The allowed amount is $1,042 and 20% of that is $208.40.
You have been asked to pay the total coinsurance amount of $208.40 for DME. DME falls within the DME and
related supplies 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 DME provided on May
21, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 11, 2020, through
May 13, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the patient had sufficient acute and chronic problems to warrant/justify admission. Acute renal
failure status post trauma especially with the underlying health conditions of this patient was sufficient for it to
be medically reasonable that patient would require two (2) or more midnights at the time of admission.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from May 11, 2020, through May 13, 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex interspinous and/or interlaminar device (CPT Code 22869).You asked the Plan to pre-approvethe services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says medical studies haven't proven that the service(s) or procedure(s) is helpful for treatment of the member's health problem.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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed. There is no documented instability. High failure rates have been reported.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 pre-approveVertiflex interspinous and/or interlaminar device (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on August 6, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan.
The Plan has network providers available who can provide the 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 practitioner services provided
to the enrollee on August 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided from May 20, 2020, through July 22, 2020, by a mental health counselor.You asked the Plan to pay forthe services. You say that you would like the Plan to pay for the services because this provider assisted you while dealing with depression.The Plan denied your request. The Plan says the provider is not eligible to participate with Medicare.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. This provider is a mental health counselor and this provider's specialty is not recognized by Medicare for performing mental health counseling.Therefore, we decided that the Plan does not have to pay forthe services provided from May 20, 2020, through July 22, 2020, by a mental health counselor
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic eye exam provided on August 11, 2020.You asked the Plan to waive the copayment forthe diagnostic eye exam. You say that the copayment should be waived because you never paid this amount before.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 show that you received the diagnostic eye exam on August 11, 2020. You are asked to pay a $45 copayment for the eye exam. Your EOC states that enrollees must pay a $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. 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 diagnostic eye exam provided on August 11, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82306, 82728, 73550, and 83540 provided on April 17, 2019.
You asked the Plan to pay for the laboratory 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 a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82306, 82728, 73550, and 83540 provided on April 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering with interpretation provided.

You asked the Plan to pay for the 3D rendering with interpretation (76377). You say that the Plan should pay this claim.The Plan denied your request. The Plan says this service is not covered separately.

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 the 3D rendering with interpretation has a bundled relationship with code 70553 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 3D rendering with interpretation provided