Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from December 5, 2019 to December 8, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not make enough money to pay this high bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $425 copayment for each day for days 1 to 4 for Medicare-covered hospital care. You have been asked to pay a $425 copayment for each day of the inpatient hospital stay. ($425 x 3 = $1,275). The inpatient hospital stay falls within the "Inpatient Hospital 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 inpatient hospital stay provided from December 5, 2019 to December 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal.
You asked the Plan to pre-approve a root canal. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a root canal
when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. Review of the file shows that you are requesting a root canal on the
left upper molar. Root canals are only covered for treatment for endodontic therapy if performed on anterior
teeth and for endodontic therapy if performed on bicuspid teeth. Based on this information, we decided that the
Plan's rules for coverage of a root canal have not been met. Therefore, we decided that the Plan does not have
to pre-approve a root canal.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from February 6, 2020 to March 10, 2020.
You asked the Plan to reduce the copayments for the physical therapy visits. You say that you were told that your copayment was $5 per visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 copayment for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. You have been asked to pay a $30 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation 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 reduce the copayments for the physical therapy visits provided from February 6, 2020 to March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services (CPT 15734) provided to the enrollee on January 6, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plandenied your request. The Plan says the records do not support the services billed.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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap."We 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 coded correctly. Our coding reviewer found the documentation submitted was reviewed, and "Muscle, myocutaneous, or fasciocutaneous flap" was not documented in the operative report.We looked at this coder'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 haveto pay forsurgical services (CPT 15734) provided to the enrollee on January 6, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis provided on November 21, 2019 by an OON provider.You asked the Plan to pay forthe prophylaxis. You say that you do not want to pay for this service because you feel it should have been covered at 100%.The Plan denied your request. The Plan says the treating provider does not have a contract with your plan as a participating provider, and is allowed to bill the difference of the allowed amount and their billed amount to you.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, you can get care from an out-of-network dental provider, but you may pay more. You are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe prophylaxis provided on November 21, 2019 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system (33289, C2624).
You asked the Plan to pre-approve the CardioMEMS system. You say that the system is medically necessary.
The Plan denied your request. The Plan says this system and procedure is still considered investigational and is
not covered.
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 CardioMEMS system. Our reviewer
says that the requested service is not medically necessary. Our physician reviewer found the efficacy of the
CardioMEMS device is uncertain at this time according to leading authorities and it is not recommended in
current guidelines for the treatment of heart failure.
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 CardioMEMS system have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS system (33289, C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided December 11, 2019 to December 20, 2019. You asked the Plan to pay for IRF care. You say that your doctors informed you that acute rehab is appropriate and medically necessary for you and a skilled nursing facility was not appropriate for you and would prolong your recovery. The Plan denied your request. The Plan says your condition is not appropriate for acute inpatient rehabilitation. Home health or therapies at a skilled nursing facility were more appropriate alternatives.
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 pay for 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 enrollee was medically stable with no evidence of need for supervision by physical therapy and rehabilitation physician or needs acute rehab nursing care. Functionally given his needs for activities of daily living and mobility assistance, he needs physical therapy (PT) and occupational therapy (OT) and does not require IRF level of therapies. The enrollee may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current medical stability and lack of medical complexity. 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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided December 11, 2019 to December 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional routine transportation trips.
You asked the Plan to pre-approve the additional transportation. You say that you would like reconsideration
because you are unable to drive yourself to your appointments. The Plan denied your request. The Plan says
your benefit only allows 30 trips for this service.
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 30 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 30 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the contrast x-ray of the hip coded 73525 provided on January 9, 2020.
You asked the Plan to pay for the contrast x-ray of the hip. 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 73525 is radiologic examination, hip, arthrography, radiological supervision and interpretation. We find that CPT code 73525 is not supported in the medical record. Specifically, the documentation submitted did not include interpretation report or arthrographic findings of the hip joint. In addition, the submitted documentation indicates that the injection procedure was therapeutic where contrast was administered for needle placement and there is arthrographic findings notes; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the contrast x-ray of the hip have not been met. Therefore, we decided that the Plan does not have to pay for the contrast x-ray of the hip coded 73525 provided on January 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy (98525 and 38792) and mastectomy (19301) provided on November 13, 2019.
You asked the Plan to pay for the biopsy and mastectomy. You say that you would like reconsideration because these services are payable to an assistant surgeon. The Plan denied your request. The Plan says the surgeon has not documented medical necessity for an assistant at surgery.
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 38525 and 38792. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Additionally, the record indicates that the assistant at surgery is not a PA, NP or CNS. Based upon this information, we find that Medicare coverage criteria for the biopsy and mastectomy have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy (98525 and 38792) and mastectomy (19301) provided on November 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the crisis intervention service provided on February 24, 2020.
You asked the Plan to waive the copayment for the crisis intervention service. You say that you never went to the hospital and you are appealing the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for Medicare-covered services. You have been asked to pay a $40 copayment for the crisis intervention service. The crisis intervention service falls within the "Outpatient mental health care" benefit category. The medical record shows you were seen for crisis services at the outpatient 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 the crisis intervention service provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on January 22, 2020.You asked the Plan to pay forthese 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 forthe drug testing rendered on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like reconsideration because you have been in and out of the hospital and inpatient rehabilitation is needed.The Plan denied your request. The Plan says you can safely receive the necessary services in a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. A less intensive, longer duration of therapy may be more appropriate.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
March 3, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct
cost sharing 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 $75
copayment per visit for in-and out-of-network emergency care. For this date of service, you have been asked to
pay the allowed amount of the claim because this amount is less than the $75 copayment for the emergency
room visit.
You have been asked to pay a $62.13 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency 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
emergency room visit provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for a nerve block and injection procedure.You asked the Plan to pre-approve anesthesia for a nerve block and injection procedure. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules saythat anesthesia for injection services are only covered for certain indications.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 anesthesia for a nerve block and injection procedure. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain with radicular symptoms. The enrollee had a prior Epidural steroid injection which gave the enrollee greater than 60% pain relief for three months. The enrollee has no documentation of morbid obesity, obstructive sleep apnea, spasticity, psychiatric illness or unstable medical condition. The American Society of Anesthesiologists Committee on Pain has specifically stated that sedation during an epidural steroid injection is rarely needed and may interfere with interpreting the results. Therefore, the enrollee does not meet criteria for the requested services.Review of the file shows that the plan uses LCD L36521 to support their denial. However, LCD L36521 is not valid for the state of MA for Part B. Therefore, we cannot use LCD L36521 to substantiate our decision.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia for a nerve block and injection procedure have not been met.Therefore, we decided that the Plandoes not have to pre-approve anesthesia for a nerve block and injection procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes and inserts (A5500 and A5512) provided on
October 22, 2019.
You asked the Plan to pay for the diabetic shoes and inserts. You say that you would like reconsideration
because these supplies were medically necessary. The Plan denied your request. The Plan says the
documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies,
or proof of delivery for the billed date of service.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket
submitted shows a date which is prior to the billed date of service. The record shows that the Plan made several
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not
have to pay for diabetic shoes and inserts (A5500 and A5512) provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided on March 6, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payments to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided on March 13, 2020.
You asked the Plan to waive the copayment for debridement. You say that the doctor only trimmed your nails and did not properly sanitize the scissors for the next patient. 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 podiatry services. You have been asked to pay the allowed amount of $44.63, which is less than the $45 copayment for debridement. Debridement falls within the podiatry 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 debridement provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection services rendered on March 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 64421 is 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 code 64421 is injection(s), anesthetic agent(s) and/or steroid;intercostal nerve, each additional level (List separately in addition to code for primary procedure).We find that CPT code 64421 is not supported in the medical record. Specifically, the add-on code was not billed with a required primary procedure code.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 forthe injection services rendered on March 10, 2020.