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

We decided that the Plan does not have to pay for a spinal x-ray (72110) provided on October 25, 2019.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed 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. In this case, the CPT Code Manual definition of code 72110 is radiologic examination, spine, lumbosacral; minimum of 4 views . We asked our coder 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 x-ray. Our reviewer says that CPT code 72110 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a radiologic examination, spine. lumbosacral; minimum of 4 views, therefore, this service cannot be verified. 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 x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a spinal x-ray (72110) provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from December 5, 2018 to December 31, 2018.
You asked the Plan to waive the coinsurance for radiation therapy. You say that you disagree with the out-of-network 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 40% coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $7,449.24, which is less than the 40% coinsurance for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and 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 radiation therapy provided from December 5, 2018 to December 31, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (E0666 and E0673) provided from October 26, 2019 to October 27, 2019.You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.In this case, the file shows that the billed dates of service do not match the date of service the enrollee received the items. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (E0666 and E0673) provided from October 26, 2019 to October 27, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for vascular embolization or occlusion (37242) provided on October 23, 2019.
You asked the Plan to pay for vascular embolization or occlusion. You say that this should be paid. The Plan denied your request. The Plan says that this code was billed inappropriately.
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 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (e.g., congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). 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 vascular embolization or occlusion. Our reviewer says that the use CPT 37242 is supported by the records. Our physician reviewer found the records show that the enrollee underwent right internal iliac artery embolization with selective catheterization contralateral right internal iliac, followed by endovascular abdominal aortic repair. A right internal iliac arteriogram was performed, documenting appropriate catheter position. Multiple 8mm by 5cm 0.035 coils were deployed within the right internal iliac artery. The coils extended from the right internal iliac artery bifurcation to the right internal iliac artery ostium. Attention was then directed to the endovascular repair of the right common iliac artery aneurysm and abdominal aortic aneurysm. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vascular embolization or occlusion have been met. Therefore, we decided that the Plan has to pay for vascular embolization or occlusion (37242) provided on October 23, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services (11056, 11720) provided on June 17, 2019 by an out of network (OON) provider. You asked the Plan to pay for OON podiatry services. You say that you were not aware there was not an active authorization. The Plan denied your request. The Plan says these services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the podiatry services (11056, 11720) provided on June 17, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on December 31, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you disagree with the charges because this was the only lab 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 20% coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services on December 31, 2019 from an out-of-network provider. The allowed is $827 and 20% of that is $165.40. Youhave been asked to pay the total coinsurance amount of $165.40 for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and 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 copayment forlaboratory services provided on December 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing of autonomic nervous system function services
provided on December 4, 2019.
You asked the Plan to pay for the testing of autonomic nervous system function services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed
are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95923 is testing of autonomic nervous system function;
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential.
We find that CPT code 95923 is not supported in the medical record. Specifically, the documentation submitted
did not include documentation of testing of autonomic nervous system function; sudomotor, including 1or more
of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory
sweat test, and changes in sympathetic skin potentia. Based on this information, we decided that Medicare rules
for coverage of the testing of autonomic nervous system function services have not been met. Therefore, we
decided that the Plan does not have to pay for the testing of autonomic nervous system function services
provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 28, 2020.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you disagree with the 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 a $10 copayment for each primary care provider visit. The medical records show that you received services beyond an annual wellness exam on January 28, 2020. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment an office visit. An office 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 for an office visit provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture.You asked the Plan to pre-approve the mandibular partial denture. You say that you need this denture because you cannot eat.The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago.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, complete/partial dentures are limited to once per arch, per 60 months. The record shows that you received a mandibular partial denture on August 21, 2017 and your complete/partial dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after May 3, 2020.
You asked the Plan to pre-approve SNF care. You say that the continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the continuation of SNF care does not meet criteria.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a valid notice no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid telephone notice was delivered two or more days before May 3, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after May 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kit and test strips. You asked the Plan to pre-approve a kit and test strips. You say that this is medically necessary. The Plan denied your request. The Plan says that there was no documentation found that would indicate you cannot use preferred products for diabetic testing supplies. The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are not a preferred provider with the Plan for diabetic supplies. Therefore, we decided that the Plan does not have to pre-approve a kit and test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to your manual wheelchair.
You asked the Plan to pre-approve repairs to your manual wheelchair. You say that you use the manual wheelchair when you go out with your family because the power wheelchair cannot be carried out. The Plan denied your request. The Plan says you have a power wheelchair under five years old that meets your mobility needs within your home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a power wheelchair. The power wheelchair serves the same purpose as a replacement manual wheelchair. The record shows you ambulate well with a walker and prosthesis. Therefore, we decided that the Plan does not have to pre-approve repairs to your manual wheelchair
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from October 27, 2019 through October 30, 2019.You asked the Plan to waive the copayment for the observation stay. You say that the copayment is supposed to be waived when you are admitted.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 $50 copayment per observation service. If emergency room and observation facility are billed on same day, the observation copayment will be taken. You have been asked to pay a $50 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" benefit category. The records show that you were admitted to outpatient observation. 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 observation stay provided from October 27, 2019 through October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D brush biopsy rendered on August 13, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of gastroesophageal reflux disease (GERD) without esophagitis. She underwent an upper endoscopy on August 13, 2019 that showed a normal esophagus with slightly irregular Z line. A two centimeter hiatal hernia was noted. While it is speculated that WATS 3D biopsy testing can potentially improve the management of patients with Barrett's esophagus and esophageal dysplasia, there are no convincing data in the medical literature demonstrating that such testing clearly improves the management and outcomes of such patients. The WATS 3D testing was not reasonable or medically necessary for the enrollee.We looked at this physician's review, the file, and Medicare rules. 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 WATS 3D brush biopsy rendered on August 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services provided from January 2, 2019 to February 11, 2019.
You asked the Plan to waive the copayment for surgical services. You say that you should not owe this much. The Plan denied your request. The Plan says these claims processed 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 outpatient surgery. You have been asked to pay $1,500 for surgical services ($150 copayment x 10 dates of service = $1,500) 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 surgical services provided from January 2, 2019 to February 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 11, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that prior authorization was not obtained.
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. You are not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 20, 2019.You asked the Plan to waive the copayment for the office visit. You say that the doctor did not specialize in Parkinson's. You say that the copayment should be returned.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 $50 copayment for each Medicare covered specialist visit. You have been asked to pay a $50 copayment for the office visit. The office 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 for the office visit provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe IRF admission and services.You asked the Planto pre-approve IRF care. You say that discharge from ACH to an IRF is medically necessary.The Plan denied your request. The Plan says that admission to an IRF does not meet criteria. The Plan must follow Medicare rules. The rules say that IRF admissionis 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrolleeis refusing blood draws. His most recent progress note reveals he has resolved leukocytosis, hyponatremia and hyperkalemia. The enrollee may benefit from physical therapy (PT) and occupational therapy (OT); however, the documentation does not indicate that the patient requires PT and OT or can tolerate this therapy on an intensive level 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 IRFadmission and services.