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

We decided that the Plan does not have to pay for burr holes (61210) provided on September 7, 2019.
You asked the Plan to pay for burr holes. You say that his code is supported in the records. The Plan denied
your request. The Plan says there is a more appropriate code for these services, 61107.
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 61210 is burr hole(s); for implanting ventricular catheter,
reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate
procedure).
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 burr holes. Our reviewer says that CPT
61210 is not supported by the medical records. Our physician reviewer found the operative note clearly states
that a twist drill hole was placed (CPT 61107). Therefore, the billing of CPT 61210 (Burr hole) is not
supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of burr holes have not been met. Therefore, we decided that the Plan does not have
to pay for burr holes (61210) provided on September 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery services provided on August 8, 2019 by an out of network provider.
You asked the Plan to pay for the cataract surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 cataract surgery services provided on August 8, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided from April 29, 2019 to September 12, 2019.
You asked the Plan to pay for the services. You say that payment should be made for this provider, who kept you in good health. The Plan denied your request. The Plan says providers must be eligible to participate in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. The rendering provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit services provided from April 29, 2019 to September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on October 24, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that the office you received the x-ray from changed locations and is now considered an outpatient hospital facility. You say you were not aware of this change. 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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasounds). You have been asked to pay a $40 copayment for the x-ray. The 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 the x-ray provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on May 1, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that medical records have been provided as part of the appeal. The Plan denied your request. The Plan says the services were performed by a non-participating provider and the May 1, 2019 appointment was not authorized by the facility. The medical records provided indicate that the member was seen for a follow up appointment. Members of the Plan must use in-network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available, out-of-area dialysis services, and in cases in which the Plan authorizes use of out-of-network providers.
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 an office visit (99214) provided on May 1, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert system.
You asked the Plan to pre-approve a Life Alert system. You say that the service is necessary. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan follows Medicare rules. Medicare rules say that Telephone Alert Systems are emergency communications systems and do not serve a diagnostic or therapeutic purpose.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Life Alert system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life Alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection services provided on June 19, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe denied codes remain not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of the denied codes is:HCPCS J0475:Injection, baclofen, 10 mg.HCPCS J7999:Compounded drug, not otherwise classified 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 forthe services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the enrollee had 20ml of a compounded drug instilled into her intrathecal pump (J7999.KD) to refill the pump reservoir (A4220). There is no evidence that the enrollee received separate injections of baclofen into the pump (J0475.KD x 2) or that 125 units of anything was instilled into the pump (J7999.KD x 125). Therefore, the billing of J0475.KD x 2 and J7999.KD x 125 are not supported.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forinjection services provided on June 19, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound guide for needle biopsy provided on August 22, 2019.
You asked the Plan to waive the copayment for the ultrasound guide. You say that you did not expect an additional copayment on top of your specialist office visit 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 $275 copayment for each Medicare-covered diagnostic radiology service. For this date of service, you have been asked to pay less than the standard $275 copayment for the ultrasound guide for needle biopsy.
You have been asked to pay a $45 copayment for the ultrasound guide. The ultrasound guide falls within the each "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 the ultrasound guide for needle biopsy provided on August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on August 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care at a skilled nursing facility (SNF).
You asked the Plan to pre-approve the continuation of SNF care. You say that the documentation provided supports the need for a continued SNF stay. The Plan denied your request. The Plan says the enrollee is currently medically stable with no complex wound care needs. The plan says that the enrollee currently has no skilled care needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care with a left hip fracture and was transferred to a SNF on January 6, 2020. The enrollee received oral medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the date of the requested authorization, the enrollee was at a contact guard to minimal assist level with functional mobility, including gait to 125 feet. The enrollee required varying assist with activities of daily living. The enrollee had cognitive impairment. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care at a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95999) provided to the enrollee on December 24, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure". We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was provided on the date of service in question. Train of four testing has an associated CPT code. The records do not show that an unlisted neurological or neuromuscular diagnostic procedure was performed on the date of service in question. 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 95999) provided to the enrollee on December 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on September 5, 2019.You asked the Plan to pay fora shingles vaccine. You say that this vaccine was recommended by your doctor.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on September 5, 2019.Benefits for a shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the breast for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says MRI is not supported for dense breasts unless there are other risk factors for disease.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found it is a true statement that mammography is limited when there is extremely dense tissue and sometimes MRI is necessary for evaluation especially in cases of equivocal mammographic or clinical findings. CMS criteria for breast MRI requires a 20% or greater lifetime risk of breast cancer based upon calculations such as the Gail Risk Model in order to qualify for MRI. This enrollee has no such calculated risk and no equivocal mammographic or physical findings to require MRI. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the breast for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chronic care management services provided on March 11, 2019.You asked the Plan to waive the copayment forthe chronic care management services. You say that you did not opt into the chronic care management program. 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 for each Medicare-covered primary care doctor visit. You have been asked to pay a $5 copayment, which is less than the standard amount, for the chronic care management services. The chronic care management services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you agreed to participate in the chronic care management program on January 18, 2019. 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 chronic care management services provided on March 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered to you on August 16, 2019.
You asked the Plan to waive the cost sharing for these services. You say that you called the plan and were referred to this provider. The Plan denied your request. The Plan says the cost sharing was 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 $40 copayment for out-of-network physician specialist services, a 35% coinsurance for out-of-network x-rays, a 25% coinsurance for out-of-network durable medical equipment and related supplies, and a 35% coinsurance for out-of-network chemotherapy and other covered Medicare Part B prescription drugs.
Review of the file shows that you had out-of-network specialist services on August 16, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the out-of-network physician specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you also received an x-ray from the out-of-network provider on August 16, 2019. You have been asked to pay a 35% coinsurance for the services, for a total of $13.26. These services fall within the out-of-network x-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you also received durable medical equipment (DME) from the out-of-network provider on August 16, 2019. You have been asked to pay a 25% coinsurance for the services, for a total of $19.72. These services fall within the out-of-network DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you also received Medicare Part B drugs from the out-of-network provider on August 16, 2019. You have been asked to pay a 35% coinsurance for the services, for a total of $19.34. These services fall within the out-of-network Medicare Part B covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $92.32. 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 cost sharing for the services rendered to you on August 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is suspected of having obstructive sleep apnea (OSA) due to snoring and witnessed apneas; however, there is no documented excessive daytime sleepiness and the Epworth score is normal at four. The clinical note dated September 5, 2019 indicates the enrollee preferred a home sleep study as the initial step and this has been ordered. The attended sleep study is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study