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

We decided that the Plan does not have to pay for the services (CPT 77062) provided to the enrollee on October 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a valid code.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Procedure code 77062 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 services (CPT 77062) provided to the enrollee on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT)
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no explanation in the submitted documentation as to why systemic therapy is not being considered for the enrollee, or less-invasive external beam radiation. There is no indication that standard chemotherapy or targeted therapy is being considered. SIRT would not be considered the standard of care and is not reasonable or medically necessary for the enrollee as first line treatment 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 25, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the billing does not reflect who provided the service. You say that you should not be charged for not seeing the specialist.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 $35 copayment per specialist visit. Covered services include physician/practitioner services, including office visits, includes services performed by a PCP, specialist, physician assistant, or nurse practitioner.You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was at the neurologyoffice, which is considered a specialist. 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 inthe Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe office visit provided on September 25, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.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 looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy provided on September 26, 2019.You asked the Planto waive the copayment fora colonoscopy. You say that this was preventative and you should not be responsible for 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a diagnostic colonoscopy. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora colonoscopy provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on August 5, 2019.You asked the Plan to waive the copayment forthe medical eye exam. You say that you needed the eye exam. You say you should not be responsible for the copayment just because the doctor found something. 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 $45 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows you were diagnosed with a retinal detachment, which is considered medical in nature.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 medical eye exam provided on August 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (19301-AS) provided on July 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the operative note includes an attestation from the provider which states she was present in the operating room for the entire case and performed the surgery herself.
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, Medicare has established the -AS modifier to report "Physician Assistant (PA) services for assistant-at-surgery, non-team member". We asked our coding 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 use of modifier -AS is not supported by the records provided. Our coding reviewer found that the medical record does not clearly state that an assistant was utilized during this procedure. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (19301-AS) provided  on July 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician's home visit provided on June 6, 2019.
You asked the Plan to pay for the physician's home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services.
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 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 a physician's home visit provided on June 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses provided on March 15, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says criteria was not met.
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 ankle foot orthoses (L1971). Our physician reviewer found the enrollee's chief complaint was ankle pain. The documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the ankles and feet. 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 ankle foot orthoses (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses provided on March 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 21, 2019 by the out of
network provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that there is no referring 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 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 August 21, 2019
by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 11, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that if you had not have been discharged from the hospital, you would not have had to call 911 for the ambulance. 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 $225 copayment for each Medicare-covered one-way trip in a ground ambulance. You have been asked to pay a $225 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 copayment for the ambulance ride provided on October 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diclofenac.
You asked the Plan to pre-approve diclofenac. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
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 diclofenac.
Benefits for diclofenac may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided August 27, 2019 to 
August 29, 2019.

You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient admission was medically necessary. The Plan denied your request. The Plan says that the acute inpatient admission was not medically necessary. An observational level of care would have been an appropriate alternative to an acute inpatient admission.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on August 27, 2019 with chest pain. The evaluation revealed stable vital signs and the physical exam was unremarkable. Labs studies revealed normal cardiac biomarkers. The enrollee underwent an electrocardiogram (EKG) and a computed tomography (CT) scan of the chest. He was admitted to telemetry and was ruled out for an acute coronary syndrome. His condition stabilized and improved and he was discharged home on August 29, 2019 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided August 27, 2019 to August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3D imaging of the brain (78607). You asked the Plan to pre-approve the 3D imaging of the brain. You say that the service is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 3D imaging of the brain. Our reviewer says that the imaging is not medically necessary. Our physician reviewer found the records submitted are insufficient to establish the 3D imaging of the brain is 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 3D imaging of the brain have not been met.Therefore, we decided that the Plan does not have to pre-approve3D imaging of the brain (78607).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded
99239 provided from August 21, 2019 to August 23, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge
summary does not support hospital discharge day management of more than 30 minutes was performed. Based
on this information, we decided that Medicare rules for coverage of the hospital discharge day management
services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge
day management services coded 99239 provided from August 21, 2019 to August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on May 14, 2019.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you went to your specialist for an injection. You say that you were informed you would only have a specialist copayment. 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 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs. You have been asked to pay $223.33, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,116.66 (20% x $1,116.66 = $223.33). The denosumab injection falls within the "Medicare Part B prescription 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 for the denosumab injection provided on May 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 5, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were advised the colonoscopy was a screening. You say that you thought insurance covered it.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 $200 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that polyps were removed, which makes this a surgical procedure. 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 colonoscopy provided on August 5, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran observation stay provided from October 11, 2019 to October 13, 2019.You asked the Plan to waive the copayment foran observation stay. You say that you were discharged from a previous stay too soon and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 copayment for observation services. You have been asked to pay a $375 copayment for an observation stay. An observation stay 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 haveto waive the copayment foran observation stay provided from October 11, 2019 to October 13, 2019