Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on October 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99152 is not supported.The Plan must follow Medicare rules. Medicare rulessay 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness or physiological status. 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 pay forthe moderate sedation services rendered on October 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoutpatient physical therapy.You asked the Plan to pre-approvephysical therapy. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the requested physical therapy is not medically necessary.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 physical therapy. 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 therapy is generally accepted as specific and effective therapy forthe enrollee's condition, but based on the provided medical records the requested 8 additional physical therapy visits are not medically reasonable and 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 physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveoutpatient physical therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on February 14, 2020.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the charges and feel that you should only owe a $30 copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. Therules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each diagnostic radiology service. You have been asked to pay a $200 copayment for a CT scan. A CT scan 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 fora CT scan provided on February 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2020.
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary and a valuable tool when determining the enrollee's treatment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 19, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for phosphatase and tensin homolog (PTEN) gene analysis testing provided on January 15, 2020.
You asked the Plan to pay for PTEN testing. You say that the treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the procedure-diagnosis code criteria have not been met for this code.
The Plan must follow Medicare rules. Medicare rules say that PTEN testing with procedure code 81321 does not require a specific associated diagnosis code (or codes) for coverage. We looked at the file and Medicare rules. The Plan says that the procedure-diagnosis code relationship for this code have not been met. Based on Medicare rules, no specific associated diagnosis code is required for procedure code 81321. Therefore, we decided that the Plan has to pay for phosphatase and tensin homolog (PTEN) gene analysis testing provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on February 28, 2019.
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you cannot afford this. The Plan denied your request. The Plan says that you are responsible for the cost-sharing.
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 Medicare-covered durable medical equipment. You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies fall within the Medicare-covered durable medical equipment 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 CPAP supplies provided on February 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
February 4, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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 a lumbar-sacral orthosis
(L0650) provided to the enrollee on February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on February 7, 2020.You asked the Plan to waive the copayment for an outpatient surgery. You say that you shouldn't have to pay for this surgery because the doctor messed up the first surgery. The Plan denied your request. The Plan says the correct copayment has been 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 $400 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $400 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery/outpatient hospital facility benefit category. This means that you have been asked to pay thecorrect 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 outpatient surgery providedby a participating provider on February 7, 2020. We note your complaint about having to get another surgery because the first one got messed up. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on
January 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON domiciliary or rest home visit. You say that the facility should have
obtained authorization. The Plan denied your request. The Plan says this service was 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 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 domiciliary or rest home visit (99336)
provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral liquid nutrition.You asked the Plan to pre-approveoral liquid nutrition. You say that you need to lose weight for a surgery.The Plan denied your request. The Plan says enteral nutrition products used orally are non-covered benefits.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The itemyou asked the Plan to pre-approve is nutritional supplement.Enteral nutrition for oral intake is not covered by Medicare or OneCare.Therefore, we decided that the Plan does not have to pre-approve the oral liquid nutrition.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 7, 2019.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 procedure codes 95907, 95886, and 95955 are not supported.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 95907 is nerve conduction studies; 1-2 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).We find that CPT codes 95907, 95886, and 95955 are not supported in the medical record. Specifically, there is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation of a complete needle electromyography to support code 95886. There is no documentation of an EEG during nonintracranial surgery to support code 95955. 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 pay for the testing services rendered on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on November 27, 2019.
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you cannot afford this. The Plan denied your request. The Plan says that you are responsible for the cost-sharing.
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 Medicare-covered durable medical equipment. You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies fall within the Medicare-covered durable medical equipment 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 CPAP supplies provided on November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on February 15, 2020.You asked the Plan to waive the copayment for a CT scan. You say that you were told that you would not have any copayment for a CT scan. The Plan denied your request. The Plan says the correct copayment has been 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 $150 copayment for outpatient hospital services. You have been asked to pay a $150 copayment for a CT scan. Radiology services are charged as an outpatient hospital service. A CT scan falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided a participating provider on February 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the heart.
You asked the Plan to pre-approve CT scan. You say that you have had a femoral popliteal bypass surgery and have a family history of heart disease. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this CT scan is 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 scan. Our reviewer says that you do not meet the Medicare criteria for the requested CT scan. Our physician reviewer found you are noted to have hyperlipidemia. There is no evidence of cardiorespiratory signs or symptoms. There is no evidence of abnormal cardiorespiratory testing. As such, the documentation does not show that the requested CT scan is medically necessary or reasonable to diagnose, treat, or otherwise manage your conditions. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the heart.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out of network (OON) provider.
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 were 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 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 medical services provided on January 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 18, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were unaware that the member did not have outof-
network coverage. The Plan denied your request. The Plan says no prior authorization was obtained.
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 provided on December 18, 2019 by
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan provided on February 6, 2020.
You asked the Plan to waive the copayment for CT scan. You say that you understand that you needed to pay $100 and the Plan would cover the remaining balance. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $275 copayment for CT scan at an outpatient hospital facility. You have been asked to pay the allowed amount of $233.07, which is less than the $275 copayment for CT scan. CT scan 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 a Computed Tomography (CT) scan provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP supplies provided on August 28, 2019.You asked the Plan to waive the coinsurance forthe CPAP supplies. You say that you cannot afford this.The Plan denied your request. The Plan says that you are responsible for the cost-sharing.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 Medicare-covered durable medical equipment. You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies fallwithin the Medicare-covered durable medical equipment 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 forthe CPAP supplies provided on August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen.You asked the Plan to pre-approve MRI. You say that a repeat MRI would allow monitoring of the enrollee's condition.The Plan denied your request. The Plan says the denial of authorization for the requested service is correct, because this MRI is not medically necessary.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 MRI. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI. Our physician reviewer found the next appropriate step if malignancy is under consideration would be directed biopsy of the liver lesion. Not only is the requested MRI a non-optimal modality for lesion monitoring, it will likely have little impact in the enrollee's long-term clinical outcome given the advanced and progressive state of his condition and associated comorbidities.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forX-Ray services provided on July 6, 2019.You asked the Plan to pay forX-Ray. You say that you are appealing with records to support service.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was enrolled in Hospice on this date of service and therefore the Plan is not responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forX-Ray services provided on July 6, 2019.