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

We decided that the Plan does not have to waive the cost shareforthe low dose CT scan provided, the cataract surgery, and the specialist office visit from April 24, 2019 to September 23, 2019.You asked the Plan to waive the cost share forthe low dose CT scan, the cataract surgery, and the specialist office visit. You say that you sent your bills in for review. You say the insurance should be paying the doctor's bills.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 45% coinsurance for out-of-network Medicare-covered screening and counselingand shared decision making visit or for the LDCT, a $295 copayment for Medicare-covered outpatient surgery at an in-network outpatient hospital, and a $50 copayment for out-of-network physician specialist services. You have been asked to pay a total of $470.36 for the low dose CT scan, the cataract surgery, and the specialist office visit. The low dose CT scan falls within the "Screening for lung cancer with low dose computed tomography (LDCT)" benefit category. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The specialist office visit falls within "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 cost share forthelow dose CTscan provided, the cataract surgery, the specialist office visit from April 24, 2019 to September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvereplacement of breast implants.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysbreast implant replacement without a definitive diagnosis of breast cancer is considered cosmetic surgery.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 surgery. Our reviewer says that the requested services are not medically reasonable or necessary. Our reviewer found you state that the original augmentation was performed for reconstructive reasons, and not cosmetic reasons. However, there is not sufficient documentation to support this claim. In addition, there is no medical documentation to support that implant removal would create a significantly abnormal appearance of the breasts.  There is insufficient medical documentation to support that implant replacement is reconstructive in nature. The treating Plastic Surgeon noted that implant replacement would be cosmetic surgery. Therefore, it should not be considered medically necessary as defined by Medicare. 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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvereplacement of breast implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided from January 6, 2020 to February 4, 2020.
You asked the Plan to pay for home infusion therapy services. You say that this is a recognized and authorized code for payment. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9347 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services provided from January 6, 2020 to February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay fornerve conduction studies (95908), needle electromyography (95886) and train of four monitoring (95999) provided on May 8, 2019.You asked the Plan to pay forthe neuromonitoring services. 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 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.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 topay for the neuromonitoring services. Our reviewer says that CPT code 95908 does not meet criteria for billing or reimbursement consideration. Documentation submitted was reviewed and does not indicate this test was completed. CPT code 95886 does not meetcriteria for billing or reimbursement consideration.  CPT code 95886 is reported when nerve conduction studies are completed and the documentation does not indicate nerve conduction studies were completed. Our reviewer found CPT code 95999 does not meet criteria for billing or reimbursement consideration. Train of four monitoring is bundled with intraoperative neuromonitoring of electromyography, billing separately is considered unbundling.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 neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay fornerve conduction studies (95908), needle electromyography (95886) and train of four monitoring (95999) provided on May 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from July 27, 2019 through July 30, 2019, August 12, 2019 through August 20, 2019 and September 15, 2019 through September 20, 2019.You asked the Plan to waive the copayment forthe inpatient stays. You say that these three visits were all for the same problem. You say that there should not be separate charges.The Plan denied your request. The Plan says the copayments 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 $295 copayment per day for days 1-5 per hospital stay. You pay nothing after day 5.You have been asked to pay a total of $2,721.38 for the inpatient stays. The inpatient stays fall 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.The records show that these were separate inpatient admissions.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 inpatient stay provided from July 27, 2019 through July 30, 2019, August 12, 2019 through August 20, 2019 and September 15, 2019 through September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee from September 21, 2019 to September 24, 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 final claim must have the appropriate Type of Bill 857.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.The provider is not contracted, so the claim does not have the correct Type of Bill. 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 lab services provided to the enrollee from September 21, 2019 to September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve stimulator for the enrollee.You asked the Plan to pre-approvethe stimulator. You say that this is medically necessary.The Plan denied your request. The Plan says the use of peripheral nerve stimulation has not been found to bea safe and effective treatment for knee osteoarthritis based on the lack of evidence in current peer-reviewed medical literature.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 stimulator. Our reviewer says that the requested stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure for pain due to osteoarthritis. The request is not medically reasonable or necessary.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 stimulatorhave not been met.Therefore, we decided that the Plan does not have to pre-approvea peripheral nerve stimulator for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 10, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that the nurse informed you that you had to go to the hospital but there was nothing wrong with you. You say that you wouldn't have accepted the ambulance if it weren't for the urgency of the nurse.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 $250 copayment for each Medicare-covered one-way trip via ground ambulance.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for all the chiropractic services provided on January 10, 2020.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says while a portion of this claim was paid, those services not directly
related to manual manipulation of the spine were denied based on the Medicare rules and the Plan contract
agreement.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that some of the services provided
were not related to manual manipulation of the spine. Those services are not covered by the Medicare or the
Plan. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on January
10, 2020 that were not related to manual manipulation of the spine.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional units of CPT 76830 and CPT 76856 provided
on January 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service was
already paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code is not supported in the medical record. Specifically, the records provided show that one
unit of CPT 76830 and one unit of CPT 76856 were provided on the date of service in question. The plan has
paid for one unit of each of these codes. The records provided do not support the additional units of CPT 76830
and CPT 76856 billed for January 29, 2020. 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 the
additional units of CPT 76830 and CPT 76856 provided on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of a CardioMEMS device. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met as the device should still be considered experimental or investigational. 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 insertion of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard (K0861) and
accessories.
You asked the Plan to pre-approve a power wheelchair, group 3 standard and accessories. You say that the
requested items are necessary. The Plan denied your request. The Plan says based on the documentation
provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for a power mobility
device or a push-rim activated power assist device to be 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 a power wheelchair, group 3 standard
and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found
the documentation indicates the enrollee can safely operate a power wheelchair. The requested Group 3 power
wheelchair with multi power option such as tilt in space and power elevating leg rests is not medically
necessary as a durable medical equipment (DME) evaluation notes the enrollee is able to meet her mobility
needs and mobility-related activities of daily living (MRADLs) with her current wheelchair. Furthermore, the
documentation indicates the enrollee does not need specialized seating or tilt and recline. For these reasons the
request for the Group 3 power wheelchair with multi power option such as tilt in space and power elevating leg
rests is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair, group 3 standard and accessories have not been met.
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard
(K0861) and accessories
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that the enrollee would benefit from additional skilled nursing, because he is not yet at the point to go home. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia Sol 60mg/ml.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has no commercial pharmacy benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia Sol 60mg/ml.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs rendered on January 22, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you have been paying a copayment for previous services, not coinsurance.The Plan denied your request. The Plan says the coinsurance was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 19% coinsurance for in-network Medicare Part B covered drugs. Review of the file shows that you received Medicare Part B drugs on January 22, 2020. You have been asked to pay a 19% coinsurance for these services, for a total of $379.77. These services fall within the in-network Medicare Part B covered drugs 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 forthe Part B drugs renderedon January 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you will not pay for a service that you did not receive. You say that the ambulance did not transport you anywhere but has still charged you. You stated that your insurance will not pay for the charge because you do not owe anything.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 9, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe MRI provided on January 21, 2020.You asked the Plan to pay forthe MRI. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations.We looked at the file, the Plan's contract and Medicare rules. The Plan's contract only advises the enrollee that prior authorization is required for "some services." The Plan contract does not advise which of the services would require prior authorization.Therefore, we decided that the Plan has to pay forthe MRI provided on January 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for insertion of heart rhythm monitor under skin provided by a participating provider on January 17, 2020.
You asked the Plan to waive the deductible and copayment for outpatient surgery. You say that the procedure did not work. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct deductible and copayment have been applied.
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 $1,250 deductible and a $175 copayment for outpatient surgery/in-network. You have been asked to pay a $1,250 deductible and a $175 copayment for outpatient surgery. The total amount you are being asked to pay is $1,425 ($1,250 +$175 = $1,425). Since an outpatient surgery was provided, the correct copayment has been applied. Outpatient surgery falls within the outpatient surgery/in-network 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 deductible and copayment for insertion of heart rhythm monitor under skin provided by a participating provider on January 17, 2020.