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

We decided that the Plan does not have to pre-approve computerized tomography (CT) scans of the neck soft
tissue and the chest.
You asked the Plan to pre-approve CT scans. 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 CT scans 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 CT scans. Our reviewer says that the
documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee has a history of Stage IV Squamous cell cancer of the right tonsil
diagnosed in 2014. The documentation supports that as outlined in NCCN Guidelines for Head and Neck
Cancers Locoregionally Advanced Disease: 6 Months to 5 Years Post-Treatment (Long-Term) is
recommended. Fleischner Society 2017 guidelines for pulmonary nodule monitoring in high-risk patients, state
that a follow up CT should be done at 3-6 months, then 18-24 months, if nodules are stable from scan to scan.
There is no recommendation by any society that yearly scans for nodules that are stable at 2 years be annually
followed, unless there is a clinical reason to suspect there is a pulmonary change. The enrollee has been
monitored for five years without apparent change. 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 CT scans have not been met. Therefore, we decided that the Plan does not have
to pre-approve computerized tomography (CT) scans of the neck soft tissue and the chest.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on November 11, 2019.
You asked the Plan to pay for the emergency department visit. 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 payable.
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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 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 emergency department visit. Our reviewer says that the documentation does not support the use of code 99285. Our coder reviewer found the documentation of the emergency room visit does not support the highest level of evaluation and management. To report an evaluation and management level, all criteria in that level must be met. Per the documentation submitted, the exam supports a detailed history, detailed examination and medical decision making was minimal. Diagnostic procedures performed are laboratory and x-ray. The medical decision making in this case better supports code 99283. Therefore, the requested code is not supported.
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 emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on November 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291, 99292) rendered by the out of network (OON) provider on January 4, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The record indicates that the transfer of the enrollee to this hospital was non-emergent. As such, the hospital had an obligation to request authorization for this service prior to the enrollee being transferred. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291, 99292) rendered by the out of network (OON) provider on January 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a paravertebral block provided on October 5, 2020.

You asked the Plan to waive the copayment for a paravertebral block. You say that you feel that you should only owe a $15 copayment and disagree with the additional 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 $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received a paravertebral block at an outpatient hospital facility on October 5, 2020. A paravertebral block is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $100 copayment. 

You have been asked to pay a $100 copayment for a paravertebral block. A paravertebral block 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 for a paravertebral block provided on October 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam and neutron beam radiotherapy.
You asked the Plan to pre-approve proton beam and neutron beam radiotherapy. 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 proton beam and neutron beam radiotherapy. 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 cancer. Per National Comprehensive Cancer Network (NCCN) compendia, brachytherapy and external beam radiotherapy are allowed and proton beam therapy is not allowed. 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 proton beam and neutron beam radiotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam and neutron beam radiotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and portable oxygen system provided on October 20, 2020.
You asked the Plan to waive the coinsurance for the oxygen concentrator and portable oxygen system. You say that you were not informed you had to pay for the oxygen. You say that you refuse to pay the copayment. The Plan denied your request. The Plan says the coinsurance 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 DME and supplies. You have been asked to pay a total of $23.41 for the oxygen concentrator and portable oxygen system.
Service
Allowed Amount
Coinsurance
Member Liability
Oxygen Concentrator
$89
20%
$17.80
Portable Oxygen System
$28.07
20%
$5.61
TOTAL:
$23.41
The oxygen concentrator and portable oxygen system fall within the "Durable medical equipment (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. 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 oxygen concentrator and portable oxygen system provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the non-emergency transportation (A0100) provided October 13, 2020.
You asked the Plan to pay for the non-emergency transportation. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that they did not receive an explanation of benefits from your primary insurance carrier.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide any documentation to refute that their transportation benefit failed here. In addition, the Plan did not give any specific information about what primary payer would be potentially responsible for this charge Therefore, we decided that the Plan has to pay for the non-emergency transportation (A0100) provided October 13, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 25, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you were told the copayment would be waived. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for Medicare-covered diagnostic radiology services ($100 ultrasound). 

You have been asked to pay a $250 copayment for the MRI. The MRI 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 MRI provided on October 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from October 13, 2020, to November 16, 2020.
You asked the Plan to pay for this service. You say that your oncologist told you these services would be helpful. The Plan denied your request. The Plan says Medicare and the Plan only cover services that involve manual manipulation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from October 13, 2020, to November 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemotherapy infusions provided from October 8, 2020, to November 19, 2020.
You asked the Plan to waive the copayment for chemotherapy infusions. You say that you have never been charged in the past and 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 $275 copayment for outpatient hospital services. You received chemotherapy infusions at an outpatient hospital facility, from October 8, 2020, to November 19, 2020, for a total of 3 visits. Because services were rendered at an outpatient hospital facility, you are responsible to pay a $275 copayment per each visit. The total amount you owe is: $275 (copayment) x 3 (visits) = $825. You have been asked to pay the total copayment amount of $825 for chemotherapy infusions. Chemotherapy infusions fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for chemotherapy infusions provided from October 8, 2020, to November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 18, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service on the claim must reflect the location of the enrollee when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim shows a place of service code as 81. The records provided do not indicate the enrollee's specimen was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for bilateral above the knee amputations. There is gastrointestinal bleeding for which testing is still being pursued. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) rendered by the out of network (OON) provider on January 5, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The record indicates that the transfer of the enrollee to this hospital was non-emergent. As such, the hospital had an obligation to request authorization for this service prior to the enrollee being transferred. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) rendered by the out of network (OON) provider on January 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve a mandibular partial denture. You say that your previous dentures are broken and need replacing. The Plan denied your request. The Plan says rules for coverage have not been met.
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. The Plan covers a mandibular partial denture once every five years. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a mandibular partial denture have not been met. Specifically, you previously received dentures in 2020 which is fewer than five years ago. The benefit for 2021 is exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion provided on February 28, 2020.
You asked the Plan to pay for the Ketamine infusion. You say that Ketamine infusions are a necessary treatment. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of Ketamine infusions for the treatment of depression.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for Ketamine infusion. Our reviewer says that the infusion was not medically necessary. Our physician reviewer found in July 2019; the International Anesthesia Research Society published the results of a systematic literature review which compiled the results from seven randomized controlled trials evaluating the long-term effectiveness of ketamine infusion for the treatment of pain. In total, the seven trials that were evaluated included 211 patients with three types of pain: neuropathic, mixed and nonneuropathic. Three of the seven studies reported significant analgesic benefit with ketamine, with a small analgesic effect that persisted for up to two weeks post-infusion. There was no difference in pain relief based on pain classification. The results suggested but did not establish, enhanced pain relief with higher doses of ketamine and in patients with complex regional pain syndrome. The analysis also concluded that additional studies enrolling a larger population of patients are needed in order to determine the efficacy of ketamine for chronic pain syndrome. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine infusion have not been met. Therefore, we decided that the Plan does not have to pay for the Ketamine infusion provided on February 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit provided on July 5, 2019.
You asked the Plan to pay for the established patient home visit. You say that you believe this claim should be reprocessed for payment. The Plan denied your request. The Plan says to bill these codes, the physician must be physically present in the enrollee's home. The Plan also says that the records do not support that a physician or non-physician practitioner were physically present, and the submitted code does not appropriately reflect the services provided.
The Plan must follow Medicare rules. Medicare rules say that home services codes 99341-99350 are paid when they are billed to report evaluation and management services provided in a private residence. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. We looked at the file and Medicare rules. The record does not support that the physician was physically present. Based on this information, we decided that Medicare rules for coverage of the established patient home visit have not been met. Therefore, we decided that the Plan does not have to pay for the established patient home visit provided on July 5, 2019.