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

We decided that the Plan does not have to pay for needle electromyography (95886) provided on November 14, 2019.
You asked the Plan to pay for the needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) . 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 needle electromyography. Our reviewer says that CPT code 95886 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted did not indicate that needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels was performed. 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 needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) provided on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic decompression of neural elements and/or excision of herniated intervertebral discs for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says the evidence is insufficient to determine the effects of this technology on health outcomes.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational technique that is the subject of ongoing clinical trials. 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 surgery have not been met.Therefore, we decided that the Plan does not haveto pre-approve endoscopic decompression of neural elements and/or excision of herniated intervertebral discs for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a Uvulopalatopharyngoplasty (UPPP).
You asked the Plan to pre-approve the UPPP surgery. You say that the enrollee has tried all other avenues of recommended treatment and has been unable to tolerate the devices. You say that this leaves the enrollee untreated and susceptible to the medical conditions of untreated obstructive sleep apnea, including hypertension, heart disease, and chronic lung disease. The Plan denied your request. The Plan says that UPPP medical necessity criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 UPPP surgery. Our reviewer says that UPPP surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has obstructive sleep apnea and has tried CPAP. There is no sleep study included with the documentation, but the level of AHI or RDI is not critical when determining eligibility for UPPP. There are clear anatomical indications for the surgery including an elongated soft palate and enlarged tonsils. Based on the physical exam and provided documentation, the surgery can be considered reasonable and 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 UPPP surgery have been met. Therefore, we decided that the Plan has to pre-approve a Uvulopalatopharyngoplasty (UPPP).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraoral panoramic radiographic image and periapical x-rays provided on February 5, 2020.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that these services are not covered by the Plan.
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 extraoral panoramic radiographic image and periapical x-rays provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 24, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like these services reconsidered and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that these services were not referred by a network provider or rendered in a participating facility.
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 physician services provided on October 24, 2019
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCabometyx and Tecentriq for the enrollee.You asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysan off-label use of a drug is medically accepted when there is evidence in or more of the compendia or in the medical literature that it works for the disease in question.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the review relates to a request for Cabometyx and Tecentriq to treat a 65 year old man with metastatic castration resistant prostate cancer and pleomorphic sarcoma. Neither drug is FDA approved for either prostate cancer or sarcoma. Neither drug is supported in any of the CMS approved compendia to treat either type of cancer. There are no PubMed citations supporting these drugs in this situation. The use is listed as not indicated, not supported or not recommended in any of the compendia.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 drugs have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCabometyx and Tecentriq for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on November 30, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $80 copayment for each Medicare-covered visit. You have been asked to pay an $80 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room visit.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 forthe emergency room visit provided on November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were medically necessary. The Plan
denied your request. The Plan says there is no network deficiency for the services, and alternate network
providers were found.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. 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 the medical services provided on January 22, 2020 by an out of network
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient clinic visit provided on December 13, 2019.
You asked the Plan to waive the coinsurance for the outpatient clinic visit. You say that you do not believe you should be responsible for the facility claim. 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 20% coinsurance for each outpatient hospital service. You have been asked to pay $22.93 which is 20% of the allowed amount for the outpatient clinic visit. The allowed amount is $114.67. ($114.67 x 20% = $22.93). The outpatient clinic visit falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient clinic visit provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker provided on March 30, 2019 by an out of network provider.You asked the Plan to pay for the walker.You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.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 walker provided on March 30, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the chest
rendered on August 21, 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 71275-26 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 71275-26 is computed tomographic angiography, chest
(noncoronary), with contrast material(s), including noncontrast images, if performed, and image
postprocessing.
We find that CPT code 71275-26 is not supported in the medical record. Specifically, the records support only
one unit of this code, which has already been paid by the Plan. 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 computed tomography angiography (CTA) of the chest rendered on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99235) provided on January 19, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this code is not payable.The Plan must follow Medicare rules. Medicare rules say that payment for a subsequent observation care code is for all the care rendered by the treating physician on the day(s) other than the initial or discharge date. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. We looked at the file and Medicare rules. The observation services in question were not provided by the ordering physician. It is inappropriate for any physician other than the ordering physician to bill observation codes. 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 forthe services (CPT 99235) provided on January 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hormone implantation (11980) provided on June 6, 2019.
You asked the Plan to pay for the hormone implantation. You say that you would like reconsideration because the pellet therapy alleviates some of your symptoms. The Plan denied your request. The Plan says this service is not covered when associated with menopause.
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 hormone implantation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. 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 hormone implantation have not been met. Therefore, we decided that the Plan does not have to pay for hormone implantation (11980) provided on June 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the Pelvis (72170) provided December 2, 2019.
You asked the Plan to pay for the x-ray. You say that multiple exams were performed. The Plan denied your request. The Plan says the records do not support that multiple exams were performed.
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 72170 is not supported in the medical record. Specifically, the exam notes submitted for each exam are all duplicates. The records do not support multiple exams. 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 an X-ray of the Pelvis (72170) provided December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered on January 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says 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 forthe special pump services rendered on January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous disc decompression provided on September 3, 2019.
You asked the Plan to pay for the percutaneous disc decompression. The Plan denied your request. The Plan says this was 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 the percutaneous disc decompression. Our reviewer says that the requested procedure was not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no clear documentation of nerve root compression on clinical exam. No imaging reports are submitted for review to confirm disc herniation and the safety of a percutaneous approach. There is no discussion of why this enrollee would not be a candidate for open surgical treatment. Therefore, this request for percutaneous disc decompression on date of service September 3, 2019, 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 the percutaneous disc decompression have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous disc decompression provided on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger.
You asked the Plan to pay for the perfusionist services. You say that this equipment was provided to the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 24, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you had the second mammogram
and an ultrasound was not needed. 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 for other outpatient diagnostic tests.
You have been asked to pay a $217.44 copayment for the ultrasound, which is less than the standard
copayment amount. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and
supplies" benefit category. The medical record shows that an ultrasound of the central right breast was
performed.
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 ultrasound provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services rendered on August 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99291 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care services spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe critical care services rendered on August 27, 2019.