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

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 22, 2019 through December 29, 2019. 
 
You asked the Plan to pay for home infusion therapy. You say that you would like reconsideration because CPT code S9328 is valid per CMS. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule. CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on December 22, 2019 through December 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for on June 14, 2019 through July 12, 2019. acute inpatient hospital care.
You say that you would like reconsideration based on the records submitted. The Plan denied your request. The
Plan says that inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the member's necessary hospital care (including earlier ED and/or observation care) would span
two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for on June 14, 2019 through July 12, 2019.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an artery pressure sensor (C2624). 
 
You asked the Plan to pre-approve the sensor. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is 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 the sensor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve an artery pressure sensor (C2624).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy services provided from
December 19, 2019 through February 27, 2020.
You asked the Plan to waive the copayment for radiation therapy services. You say that you would not have
gone through with the services if you knew the cost. You say that you should only pay $25 per visit. The Plan
denied your request. The Plan says the copayments 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 $60
copayment for radiation therapy performed at a freestanding radiological facility or physician's office.
You have been asked to pay a $60 copayment for each radiation therapy service. The total amount you owe is
$2,040 ($60/visit x 34 visits = $2,040). Radiation therapy services fall within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
radiation therapy services provided from December 19, 2019 through February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance (E0486).
You asked the Plan to pre-approve the appliance. You say that the appliance is medically necessary. The Plan
denied your request. The Plan says rules for coverage were not met.
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 appliance. Our reviewer says that
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer
found there has been no indication as required of any history of hypertension, ischemic heart disease or history
of stroke. There has also been no supplied documentation of a preliminary exam by a provider that led to the
ordering of a sleep study as is required under the criteria.
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 appliance have not been met. Therefore, we decided that the Plan does not
have to pre-approve an oral appliance (E0486).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and tub bench.
You asked the Plan to pre-approve a shower chair and tub bench. You say that you have been approved for a
padded shower chair in the past. You say that you received the exact same model chair from your past supplier
and that it is a transfer bench and shower chair two-in-one. The Plan denied your request. The Plan says this
item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs and tub benches are not covered
because they are not primarily medical in nature.
While a shower chair and tub bench may be appropriate in this case, neither the Plan nor Medicare offers
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and tub
bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided on December 28, 2019.
You asked the Plan to pay for the wrist hand orthosis. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the records do not support the supplies billed.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by
Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition
to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or
replacement (if applicable).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the wrist hand orthosis have not been met. The record indicates that the Plan requested progress
notes to indicate the ordering provider discussed the need for the billed supply code. There is insufficient
information to validate the supplies billed. Therefore, we decided that the Plan does not have to pay for wrist
hand orthosis (L3916) provided on December 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a diagnostic colonoscopy and specialist
services provided on December 11, 2019.
You asked the Plan to waive the copayments for a diagnostic colonoscopy and specialist services. You say that
the enrollee is being charged two copayments for the same visit. The Plan denied your request. The Plan says
the claims were processed correctly and the enrollee is 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). The contract with the Plan clearly says that enrollee's must pay a
$200 copayment for outpatient surgery services provided in an ambulatory surgical center. The contract with
the Plan also clearly says that enrollee's must pay a $30 copayment for specialist services.
The enrollee has been asked to pay the total copayment amount of $230 for a diagnostic colonoscopy and
specialist services. A diagnostic colonoscopy falls within the outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers benefit category. Specialist services fall within the
physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee
has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the
Plan does not have to waive the copayments for a diagnostic colonoscopy and specialist services provided on
December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve decompressive laminectomy with coflex at L3-4 and
L4-5 for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says this is contraindicated in patients with prior fusion and compromised vertebral bodies.
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 surgery. Our reviewer says that the
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no documented spinal instability. The Coflex device remains experimental at this time. More
research is needed to show safety and efficacy.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve decompressive laminectomy with coflex at L3-4 and L4-5 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond May 7, 2020.
You asked the Plan to pre-approve the SNF care. You say that the enrollee requires daily skilled services due to
a change in condition. The Plan denied your request. The Plan says the documentation does not show that daily
skilled care is medically necessary.
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 SNF care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee is requiring assistance for all
care. There are no complex wound care needs or IV medication requirements. There are no nursing or therapy
needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The claimant's vital signs are
stable and SNF care above custodial care setting is 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 SNF care have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) care beyond May 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from November 16, 2019 to
December 13, 2019 by a provider that does not participate in Medicare.
You asked the Plan to pay for home health services. You say that this was medically necessary and a covered
benefit. The Plan denied your request. The Plan says the provider in question does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The provider you received these services from does not participate in
Medicare, meaning these services are not covered. Based on this information, we decided that Medicare rules
for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to
pay for home health services provided from November 16, 2019 to December 13, 2019 by a provider that does
not participate in Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
You asked the Plan to pre-approve the knee RFA procedure. You say that it is felt that this should be covered
since this treatment is helpful for his pain. The Plan denied your request. The Plan says this procedure is not
considered reasonable and 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 the knee RFA procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this is an experimental/ investigational technique that is the subject of on-going
clinical trials. He is not enrolled in a clinical trial. Therefore, the request is deemed 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 the knee RFA procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care you received from
November 22, 2019, to November 24, 2019.
You asked the Plan to waive the copayment. You say that you should have no copayment. The Plan denied
your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120
copayment for emergency care.
Review of the file shows that you were provided emergency services from November 22, 2019, to November
24, 2019. You have been asked to pay a $120 copayment for the services. The services fall within the
emergency care 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 emergency care you
received from November 22, 2019, to November 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
November 13, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not informed
of the charges ahead of time. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on November 13, 2019. The allowed amount is $1,214.39 and 20% of
that is $242.88.
You have been asked to pay the total coinsurance amount of $242.88 for a Medicare Part B drug. A Medicare
Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for a Medicare Part B drug provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on December 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the documentation submitted did not include a lab order; therefore, the billed service cannot be
verified.
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 the denied codes is:
CPT 85651:
Sedimentation rate, erythrocyte; non-automated
CPT 80053:
Comprehensive metabolic panel
CPT 82610:
Cystatin C
CPT 86140:
C-reactive protein
CPT 82306:
Vitamin D; 25 hydroxy, includes fraction(s), if performed
CPT 85025:
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential
WBC count
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 services. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted
was reviewed, and does not support CPT codes 85651, 50053, 82610, 86140, 823140, 82306, 85025. A signed
physician's order must be retained on file for intent to order labs.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services provided to the enrollee on December 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November
7, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be charged a
copayment because the physician assistant you saw is not a specialist. 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 $50
copayment per visit for urgently needed services.
You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. The record shows the place of service for this visit was at an
urgent care center.
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 urgent care visit provided on November 7, 2019.