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

We decided that the Plan does not have to pay for the services (CPT 73501) provided on December 30, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not separately payable.The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. We looked at the file and Medicare rules.Procedure code 11042 is part of an edit pair with procedure code 15271. Procedure code 73502is a column one code, and procedure code 73501is a column two code. Procedure code 73502has been paid for this date of service, which means that procedure code 73501is not eligible for payment.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 73501) provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 8, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 to the enrollee by an out-of-network provider on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound cleanser.You asked the Plan to pay for the wound cleanser (A6260). You say that you need the wound cleanser.The Plan denied your request. The Plan says wound cleanser is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at review the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound cleanser (A6260) have not been met.Therefore, we decided that the Plan does not have to pay for the wound cleanser.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital, ambulance, x-ray and lab services provided August 27, 2019 to October 8, 2019.
You asked the Plan to waive the copayments for the medical services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayments were 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 $225 copayment for each inpatient admission, a $125 copayment for each Ambulance transport, a $10 copayment for outpatient hospital lab services and a $20 copayment for x-rays in the outpatient hospital setting. You have been asked to pay $380 in copayments for a hospital admission, an ambulance transport, labs and an x-ray in the outpatient setting. 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 inpatient hospital, ambulance, x-ray and lab services provided August 27, 2019 to October 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided on February 1, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. We looked at the file and Medicare rules.The services in question were provided during an inpatient stay. It is inappropriate to bill services with an outpatient place of service code during an inpatient stay. The services must be billed with an inpatient place of service.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 71045) provided on February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 5,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you should not owe anything for
services. 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 $25
copayment for specialist services.
You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist visit provided on January 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen (2-liter) with nasal cannula for the enrollee.You asked the Plan to pre-approve the oxygen. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  To qualify for home oxygen, the patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg orarterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.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 oxygen. Our reviewer says that the requested oxygen is not medically reasonable or necessary. Our physician reviewer found there is no documentation of hypoxemia. The enrollee's oxygen saturation did not drop below 88% during overnight oximetry, and therefore does not meet Medicare criteria. Supplemental oxygen is considered 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 oxygen have not been met.Therefore, we decided that the Plan does not have to pre-approve oxygen (2-liter) with nasal cannula for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study for the enrollee.
You asked the Plan to pre-approve the study. You say that the insurance won't continue to pay for the enrollee's oxygen for CPAP without a sleep study. The Plan denied your request. The Plan says there is no requirement for a new sleep test.
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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an attended polysomnography (PSG) is considered not medically necessary. The enrollee has obstructive sleep apnea, and is on CPAP with oxygen. Overnight oximetry while on CPAP breathing room air confirmed the need for supplemental oxygen, with saturations less than or equal to 88% for more than five minutes. There is no need for a repeat PSG.
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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided on December 8, 2019 by an out of network (OON) provider.You asked the Plan to pay for the ambulance services. You say that a prior authorization was attempted and declined at the time. The transport was medically necessary for the enrollee. Please reverse the denial and process for payment The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided on December 8, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 85300-26, 85303-26, 85306-26, 86022-26, 86147-26, 86147-26, 91, and 85240-26 provided on November 20, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. The file shows that the laboratory services have a PC/TC component of 9. These services are not reimbursable when submitted with the Professional Component (Modifier 26). The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers 26 and TC cannot be used with these codes. Therefore, we decided that the Plan does not have to pay for CPT codes 85300-26, 85303-26, 85306-26, 86022-26, 86147-26, 86147-26, 91, and 85240-26 provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on January 8, 2020.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says that routine
vision hardware services are not covered when provided by providers that do not contract with the member's
network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when received from a network provider.
We looked at the file and the Plan's rules. The file indicates you did not receive these services from a network
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have
not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided on
January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) purchased November 20, 2019.You asked the Plan to pay for the deluxe frames. You say that you feel the glasses you got after having cataract surgery should be covered.The Plan denied your request. The Plan says deluxe frames is not covered under the plan benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of Medicare covered standard glasses or contacts after each cataract surgery.We looked at the file and the Plan's rules. Deluxeframes is not covered under the plan benefits. Only standard frames are covered.  Based on this information, we decided that the Plan's rules for coverage of the deluxe frames have not been met.Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025) purchased November 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional physical therapy visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the four approved visits are enough to finish treatment with the therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested services are not generally accepted as specific and effective therapy for you, when there is no improvement in range of motion or function. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not documented as part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition, or to slow and prevent further deterioration. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided in an outpatient hospital facility on December 27, 2019.You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because this was necessary for a surgical procedure and should be included in the surgery copayment.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 $50 copayment for x-rays provided in an outpatient hospital facility. You have been asked to pay a $50 copayment for an X-ray. An X-ray falls 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 copayment for an X-ray provided in an outpatient hospital facility on December 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on December 21, 2019.
You asked the Plan to pay for the cerebral perfusion analysis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is considered not reasonable and necessary by Medicare and is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cerebral perfusion analysis have not been met. Specifically, per Local Coverage Article: Billing and Coding: Non-Covered Services (A57641), cerebral perfusion analysis (0042T) is considered not proven effective or not medically reasonable and necessary. Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 23, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 23, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy duty wheelchair and attachments.
You asked the Plan to pre-approve an extra heavy duty wheelchair and attachments. The Plan denied your
request. The Plan says that the documentation indicates that the requested use of the wheelchair is for use
outside of the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve an extra heavy duty wheelchair and attachments.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous and/or interlaminar device.You asked the Plan to pre-approve Superion interspinous and/or interlaminar device. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 Superion interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested spacer is considered experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion interspinous and/or interlaminar device have not been met.Therefore, we decided that the Plan does not have to pre-approve Superion interspinous and/or interlaminar device.