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

We decided that the Plan does not have to pre-approvea percutaneous transcatheterclosure procedure.You asked the Plan to pre-approvethe procedure. The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that LAAC is covered when the above criteria are 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 pre-approve the procedure. Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical item."] Our physician reviewer found that the enrollee has atrial fibrillation treated with Xarelto and no documented medical contraindication to anticoagulation. Warfarin can be used if cost on Xarelto is a concern and frequent skin lesion removal is not a medical contraindication to anticoagulation. The LCD coverage criteria are not met.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea percutaneous transcatheter closure procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic blood pressure monitor (A4670).
You asked the Plan to pay for an automatic blood pressure monitor. You say that the monitor is necessary to
keep your blood pressure at the right level. The Plan denied your request. The Plan says this item is not
covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pay for automatic blood pressure monitor (A4670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and extraction provided on October 22,
2019 and November 25, 2019.
You asked the Plan to pay for the panoramic x-ray and extraction. The Plan denied your request. The Plan says
these services are not covered under 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
panoramic x-ray and extraction provided on October 22, 2019 and November 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43239) provided on
September 5, 2019.
You asked the Plan to pay for the esophagogastroduodenoscopy. 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 service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 43239 is esophagogastroduodenoscopy, flexible,
transoral; with biopsy, single or multiple.
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 esophagogastroduodenoscopy. Our reviewer says that
CPT code 43239 does not meet criteria for billing or reimbursement consideration. Our reviewer found the
documentation does not indicate that esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or
multiple 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 esophagogastroduodenoscopy have not been met. Therefore, we decided
that the Plan does not have to pay for an esophagogastroduodenoscopy (43239) provided on September 5,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on February 11, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stand-up shower conversion.
You asked the Plan to pre-approve a stand-up shower conversion. You say that you cannot walk or lift your leg to get into your bathtub. The Plan denied your request. The Plan says a stand-up shower conversion is not covered by Medicare or the Plan
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Also, Medicare does not cover home modifications. Therefore, we decided that the Plan does not have to pre-approve a stand-up shower conversion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J7324) provided January 2 to
January 13, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived.
The Plan denied your request. The Plan says the correct cost-sharing was 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 20%
coinsurance for Part B drugs.
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 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 injections (J7324) provided
January 2 to January 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures (97112) provided on December 23,
2019 through December 26, 2019.
You asked the Plan to pay for the therapeutic procedures. 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 number of units 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 97112 is therapeutic procedure, 1 or more areas, each 15
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities.
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 therapeutic procedures. Our reviewer says that CPT code
97112 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records provided do not include sufficient information to corroborate that 3 units of CPT 97112 was performed
on December 23, 2019, and December 26, 2019, therefore these services cannot be verified.
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 therapeutic procedures have not been met. Therefore, we decided that the
Plan does not have to pay for therapeutic procedures (97112) provided on December 23, 2019 through
December 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work on January 14, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you think the $10 copayment should be a part of your $250 outpatient surgery 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 a $10 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is considered a separate service.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory work provided on January 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forlaboratory services and a CT scan provided on October 14, 2019 and October 23, 2019.You asked the Plan to waive the copayments forlaboratory services and a CT scan. You say that you disagree with the charges because your doctor ordered the tests.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 $35 copayment for lab services and a $225 copayment for diagnostic radiology services. You received laboratory services on October 14, 2019. Therefore, you are responsible to pay the $35 copayment. You received a CT scan on October 23, 2019. Therefore, you are responsible to pay the allowed amount of $168.24. The total amount you owe is: $203.24.You have been asked to pay the total copayment amount of $203.24 for laboratory services and a CT scan. Laboratory services and a CT scan fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forlaboratory services and a CT scan provided on October 14, 2019 and October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for morphine sulphate injection (J2774), fentanyl citrate injection (J3010) and unclassified drugs (J3490) provided on July 25, 2019.
You asked the Plan to pay for the drugs. 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. In this case, the CPT Code Manual definition of code J2774 is injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg. The CPT Code Manual definition of code J3010 is injection, fentanyl citrate, 0.1 mg. The CPT Code Manual definition of code J3490 is unclassified drugs. 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 drugs. Our reviewer says that CPT codes J2774, J3010 and J3490 do not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted does not support the services billed. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pay for morphine sulphate injection (J2774), fentanyl citrate injection (J3010) and unclassified drugs (J3490) provided on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services and hospital visits provided from October 22, 2019 to December 19, 2019.
You asked the Plan to waive the copayment for radiology services and hospital visits. You say that you should not be charged two copayments for each service. The Plan denied your request. The Plan says these services processed 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 $30 copayment for diagnostic and therapeutic radiology services and a $100 copayment for each outpatient hospital visit. You have been asked to pay a $30 copayment for each radiology service and a $100 copayment for each outpatient hospital 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 for radiology services and hospital visits provided from October 22, 2019 to December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the trigger point injections provided on January 3, 2020 and January 15, 2020.
You asked the Plan to waive the copayments for the trigger point injections. You say that you do not feel you are responsible for these charges. You say the physician cannot bill at an ambulatory surgical center. 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 $175 copayment per visit for surgery performed in an ambulatory surgical center (ASC) or in an outpatient hospital facility. You have been asked to pay a $175 copayment for the trigger point injections on each date of service. The trigger point injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed separately by the facility and the physician.
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 copayments for the trigger point injections provided on January 3, 2020 and January 15, 2020.
Your complaint about the billing practices is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient behavioral health services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. The Plan denied your request. The Plan says that the enrollee had no aggression, self-injurious behavior, or threatening behavior.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services beyond May 8, 2020 was requested for the enrollee. 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 inpatient psychiatric hospital services. Our physician reviewer found that this enrollee did require inpatient mental health treatment beyond the dates in question as noted above as he was a danger to himself, but not others. It did appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition, or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. The services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does meet the criteria for treatment beyond the date in question of May 9, 2020 forward as he was showing suicidal ideation and thoughts with no homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve continued inpatient behavioral health services.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670).You asked the Plan to pre-approve automatic blood pressure monitor. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 8, 2019 to September 13, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that you believe that the care given to this enrollee was medically appropriate, clinically necessary and financially efficient.The Plan denied your request. The Plan says the hospital did not provide sufficient information to allow a reasonable conclusion that the second admission was not preventable.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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department from a rehabilitation center with acute on chronic hypoxic failure. Documentation notes the enrollee had been discharged from the hospital to the rehabilitation center on 9/6/19. Requests for records relating to initial hospital encounter were not available for review. Without this, evaluation of pre-mature discharge cannot be completed. The medical necessity of a second, inpatient stay cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided September 8, 2019 to September 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical facet block (64490, 64491, and 64492).
You asked the Plan to pre-approve a cervical facet block. You say that the requested cervical facet block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested cervical facet block.
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 a cervical facet block. Our reviewer says that the enrollee does not meet criteria for the requested cervical facet block. Our physician reviewer found the enrollee is with multiple chronic pain complaints. Based on the documentation provided, the MRI shows severe central spinal stenosis. Criteria for facet injections are not met. There is canal stenosis present. 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 cervical facet block have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical facet block (64490, 64491, and 64492).