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

We decided that the Plan has to pay for initial hospital care services (99223).

You asked the Plan to pay for the initial hospital care services. You say that you would like reconsideration because this provider should be paid for the service that was performed. The Plan denied your request. The Plan says that the member was not inpatient status on the billed date of service.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the record submitted appears incomplete as there is no documentation of the member's status on the billed date of service. Therefore, we decided that the Plan has to pay for initial hospital care services (99223).

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 pre-approve a sacroiliac joint injection.

You asked the Plan to pre-approve the requested services. You say that you cannot get out of the chair without severe pain. The Plan denied your request. The Plan says there is no clear exam or imaging documenting the sacroiliac joint as the pain source.

The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under certain medical 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 the requested services. Our physician reviewer found that you have chronic low back pain and sacroiliitis. You take Ibuprofen and Lidocaine patches. You are doing a home exercise program. There is no physical exam of the SI joint documented in the progress notes. There is no physical exam that confirms the diagnosis of sacroiliitis. Therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).You asked the Plan to pre-approvea pneumatic compression device. You say that this service is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says there is no documentation in the medical records that the member has tried and failed a basic compression pump.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.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 pneumatic compression device. Ourreviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found there is no evidence that a 4-weektrial with E0650 or E0651 was completed. The record only documents that a 5-minuteE0651 trial was completed .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 pneumatic compression device have not been met.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction testing (95887, 95907, 95937).

You asked the Plan to pay for the nerve conduction testing. You say that the services were medically necessary. 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.

We find that CPT code 95887, 95907, & 95937 is not supported in the medical record. Specifically, the technical report does not include documentation of a nerve conduction study to confirm procedure was performed. CPT code 95887 is an add-on code and cannot be paid since the primary code is not supported. CPT code 95937 cannot be separately paid when reported for Train-of-Four testing performed during intraoperative neuromonitoring. Based on this information, we decided that Medicare rules for coverage of the nerve conduction testing have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction testing (95887, 95907, 95937).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the occipital nerve block.

You asked the Plan to pay for the nerve block. The Plan denied your request. The Plan says this is an experimental procedure.

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 the nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that an occipital nerve block is considered an experimental/investigational procedure at this time. 

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 nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the occipital nerve block.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you do not agree with this. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 had network providers available who could have provided 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 lab work provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic testing supplies (A4235, A4253, A4258, A4259).

You asked the Plan to pay for the diabetic testing supplies. You say that these items were medically necessary.
The Plan denied your request. The Plan says the documentation does not support the services billed.

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 physician order. The physician orders provided are dated after the 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 testing supplies (A4235, A4253,
A4258, A4259).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided by an out of network (OON) provider.

You asked the Plan to pay for home health services. You say that you were unable to call customer service because you are deaf. You say that you were unable to get into contact with your primary care physician. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 had network providers available who could have provided 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 home health services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided an out-of-network provider.

You asked the Plan to pay for the nursing facility care. You say that the treatment was medically necessary, and payment should be granted. The Plan denied your request. The Plan says the provider is not contracted with the health plan.

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 had network providers available who could have provided 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 nursing facility care provided an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing services and the localized delivery of antimicrobial agents services.

You asked the Plan to pay for the periodontal scaling and root planing services and the localized delivery of antimicrobial agents. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a ocvered 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing services and the localized delivery of antimicrobial agents services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids.

You asked the Plan to pay for the services. You say that the rendering provider should be considered an
acceptable vendor and reimbursable. The Plan denied your request. The Plan says hearing aids must be
purchased through the plan's vendor.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided by a plan-approved vendor.

The rendering provider is not plan-approved. Based on this information, we decided that the Plan's rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for
hearing aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three additional intraoral periapical x-rays (D0230).

You asked the Plan to pre-approve the services. You say that you were not aware of the limitations. The Plan denied your request. The Plan says the claim was processed correctly.

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, the requested items or services are not among those covered under this benefit. The plan only pays for one of these services per year. Four x-rays were billed on the date of service at issue in this case, and one was paid by the plan. The additional x-rays cannot be covered. Therefore, we decided that the Plan does not have to pre-approve three additional intraoral periapical x-rays (D0230).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a head computed tomography (CT) scan (70450).

You asked the Plan to pay for a head CT scan. You say that this procedure was performed and is not a duplicate. The Plan denied your request. The Plan says this procedure is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496, which was billed by a different provided in the same specialty and practice, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a head computed tomography (CT) scan (70450).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension and infection controls supplies used
during anesthesia services provided billed with code S1015 and S8301.

You asked the Plan to pay for the billed supplies. You say that these were billed correctly as you provide
anesthesia in the office setting. As such, you are able to bill for all the supplies necessary to provide the service.
The Plan denied your request. The Plan says the S-codes billed in this case are not payable by Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

Codes S1015 and S8301 have a status indicator of "I" in the Physician Fee Schedule. This means that they are
invalid for Medicare billing. Based on this information, we decided that Medicare rules for coverage of the
billed supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing
extension and infection controls supplies used during anesthesia services provided billed with code S1015 and S8301.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the zoster (shingles) vaccine.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for the zoster (shingles) vaccine.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the transvaginal ultrasound (76830).

You asked the Plan to waive or reduce the copayment for the ultrasound. You say that you thought this service would only cost you $7. You say the full bill you received is too much. The Plan denied your request. The Plan says ultrasounds are subject to a $100 copayment. The Plan also reviewed your call logs with customer service and did not find evidence that one of their representatives told you there would only be a $7 copayment.

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 $100 copayment for radiological diagnostic services, not including x-rays.

You have been asked to pay a $84.32 copayment for the ultrasound. Only standard x-ray exams require a $7 copayment. The service you received was an ultrasound. An ultrasound falls within the radiological diagnostic services benefit category. A diagnostic radiology service requires specialized equipment beyond standard x-ray equipment and must be performed by specially trained or certified personnel. Examples include, but are not limited to, specialized scans, nuclear studies, and ultrasounds. 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 or reduce the copayment for the transvaginal ultrasound (76830).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43246).

You asked the Plan to pay for an esophagogastroduodenoscopy. You say that this is supported. The Plan denied your request. The Plan says there is no record of the billed date of 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.

We find that CPT code 43246 is not supported in the medical record. Specifically, the submitted medical records do not include documentation for the billed date of service, so this service cannot be verified. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43246).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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 codes 81403, 81311, 81275, and 81210 are 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.

We find that CPT codes 81403, 81311, 81275, and 81210 are not supported in the medical record. Specifically, there are no laboratory results 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 laboratory services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services you received.

You asked the Plan to waive the copayment. You say that the plan has paid for this in the past. The Plan denied your request. The Plan says you are responsible for the copayment.

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 $380 copayment for Medicare-covered outpatient surgery in an outpatient hospital setting.

Review of the file shows that you had outpatient surgery. You have been asked to pay a $380 copayment for the services. The services fall within the outpatient surgery 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 surgical services you received.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says this service required prior authorization from a non-contracted provider.

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 did not pre-approve the diagnostic radiology services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider.

You asked the Plan to waive the copayment for a biopsy. You say that this was a follow up procedure. The Plan denied your request. The Plan says the correct copayment has 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for outpatient surgery.

The enrollee has been asked to pay a $225 copayment for a biopsy. The correct copayment has been applied to the biopsy that was provided. A biopsy falls within the outpatient surgery benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider.