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

We decided that the Plan has to pay for colectomy (CPT 44141) services provided to the enrollee on October 29, 2019.
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 that Current Procedural Terminology (CPT) code 44141 (1 unit) remains 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 44141 is "colectomy, partial; with skin level cecostomy or colostomy." 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 reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found the documentation shows that the enrollee underwent a partial colectomy with a colotomy and an ileostomy. A colotomy is not a mucofistula. An ileostomy is considered a colostomy in this situation. Therefore, the documentation supports the billing of CPT 44141. 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 been met. Therefore, we decided that the Plan has to pay for colectomy (CPT 44141) services provided to the enrollee on October 29, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 6, 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 laboratory services rendered on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter and lubricant provided on January 27, 2020.
You asked the Plan to waive the coinsurance for the catheter and lubricant. You say that you cannot live without these supplies. You say that you think it's unfair for the cost to increase. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for prosthetic devices and medical supplies. Covered services include devices (other than dental) that replace all or part of a body part or function. You have been asked to pay a total of $91.20 for the catheter and lubricant. The catheter and lubricant fall within the "Prosthetic devices 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 the catheter and lubricant provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on June 19, 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 procedure code 20550 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 20550 is injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia"). We find that CPT code 20550 is not supported in the medical record. Specifically, the documentation was altered and does not support that the injection of a single tendon sheath or ligament was performed for the billed date of service. 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 injection services rendered on June 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on January 6, 2020 through January 9, 2020.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the member's hospice was terminated on January 6, 2020. The Plan denied your request. The Plan says Original Medicare would be responsible for the payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 6, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided on January 6, 2020 through January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 9, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you did not receive services and 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 $45 copayment a specialist visit. The medical records show that you received a specialist visit on January 9, 2020. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to adjust the cost sharing liability for the hearing aids (V5261) provided on August 2, 2019.
You asked the Plan to adjust the cost sharing liability to $595 per hearing aid. You say that you have been overcharged for the hearing aids purchased. The Plan denied your request. The Plan says that the claim for the hearing aids has been processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $595, $695, or $895 copayment per ear, depending on the Tier selected for hearing aids. The Plan says that you must pay $3,790 for the hearing aids. Based on the Plan contract, however, you cannot be asked to pay more than either a $595, $695 or $895 copayment per hearing aid, depending on the tier. The contract that you signed with the provider indicated that they were giving you an estimate based on Plan benefits but did not indicate that services would not be covered. The Plan supplemental benefit states that your copayment is $595, $695 or $895, with no clear explanation of how the tier levels are assigned. It would be unreasonable to expect you to believe that the hearing aids would not be covered. Since the EOC is not clear on tier levels and when the lower copayments apply versus the higher copayment, you should only be charged the lower end of the copayment of $595 per ear. Therefore, we decided that the Plan has to adjust the cost sharing liability to $595 per hearing aid, for the hearing aids (V5261) provided on August 2, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 6, 2019.
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 the records do not support the service 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 coded correctly. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence of a provider's concern for drug abuse/misuse. Additionally, there is no evidence that a UDS was obtained, reviewed and different than expected. Therefore, the documentation does not support that the provided, broad-sweeping, confirmatory UDT was medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. The Plan denied your request. The Plan says this is considered maintenance therapy.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 chiropractic services. Our reviewer says that the requested chiropractic services are not medically reasonable and necessary. Our physician reviewer found that there is little evidence of improvement in complaints, findings, diagnoses and treatment, with no evidence that further clinical improvement will likely occur with additional treatments, the treatments are considered maintenance therapy and are not supported or allowed per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 16, 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 are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on December 16, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve facet joint injections and a sacroiliac joint injection. We decided that the Plan does not have to pre-approve facet joint injections and a sacroiliac joint injection to be performed on the same date of service.
You asked the Plan to pre-approve facet joint injections and a sacroiliac joint injection. You say that the enrollee has benefited from both injections and both should be repeated. The Plan says that you have not documented that only one injection will be given on the date of service.
We decided that the Plan has to pre-approve facet joint injections and a sacroiliac joint injection. We also decided that the Plan does not have to pre-approve facet joint injections and a sacroiliac joint injection to be performed on the same date of service.
The Plan follows Medicare rules. Medicare rules say that it is not routinely necessary for multiple blocks (e.g., epidural block, sympathetic block) to be provided to a patient on the same day as facet joint injections. Multiple blocks on the same day could lead to improper or lack of diagnosis. 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 facet joint injections and a sacroiliac joint injection. Our reviewer says that both sets of procedures are indicated and medically reasonable and necessary but they cannot be done on the same day. Our physician reviewer found the issue is that pain generator could not be correctly identified. Therefore, the facet medial branch blocks are medically necessary and the sacroiliac joint injections should be performed on another day. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections and a sacroiliac joint injection have been met. Therefore, we decided that the Plan has to pre-approve facet joint injections and a sacroiliac joint injection, but does not have to pre-approve facet joint injections and a sacroiliac joint injection to be performed on the same date of service.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on October 21, 2019.
You asked the Plan to waive the copayment for these services. You say that the services should be covered under your routine physical and have no copayment. The Plan denied your request. The Plan says the copayment was 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 $15 copayment for Medicare-covered lab tests.
Review of the file shows that you received lab services on October 21, 2019. These services fall outside of the scope of an annual physical. You have been asked to pay a $15 copayment for these services. These services fall within the Medicare-covered lab tests 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 laboratory services rendered on October 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from September 12,
2019 to September 30, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that they never mentioned a copayment.
You say the copayment amount is ridiculous. 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 $250
copayment per day, days 1 to 58 at an out-of-network skilled nursing facility.
You have been asked to pay a $2,881.93 copayment for the SNF stay. The SNF stay falls within the "Skilled
nursing facility (SNF) care" benefit category. The record shows you met your maximum out-of-pocket amount
and therefore have been asked to pay less than the standard copayment for the SNF stay.
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 stay provided from September 12, 2019 to
September 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician certification for home health services provided on December 5, 2019.
You asked the Plan to waive the copayment for the physician certification for home health services. You say that you do not agree with the $10 copayment because you have a $0 copayment for home health services. 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 $10 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $10 copayment for the physician certification for home health services. The physician certification for home health services falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the service you received is performed by another provider in order to provide authorization for home health care service eligibility.
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 physician certification for home health services provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95909), needle electromyography (95885) and train of four monitoring (95999) provided on February 25, 2019.
You asked the Plan to pay for the neurophysiologic monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does 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 95909 is nerve conduction studies; 5-6 studies. The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. 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 neurophysiologic monitoring. Our reviewer says that the documentation does not support the billing of CPT codes 95909, 95885 or 95999. Our physician reviewer found the enrollee did not undergo nerve conduction studies (95909). Intraoperative spontaneous and triggered EMG monitoring uses codes 96861, 95862 and 95870. Train of four monitoring is considered part of the overall monitoring code (95940, 95941) and is not separately billable (95999). 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 neurophysiologic monitoring have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95909), needle electromyography (95885) and train of four monitoring (95999) provided on February 25, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019.
You asked the Plan to pay for the laboratory services. You say that the laboratory services are covered under Medicare. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 19, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 31, 2019.