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

We decided that the Plan does not have to waive the copayment fora diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) provided on December 20, 2019.You asked the Plan to waive the copayment forthe diagnostic mammography and diagnostic digital breast tomosynthesis. You say that you were not aware you would be billed a copayment for the services.The Plan denied your request. The Plan says the diagnosis on the claim indicates you are being treated or monitored for an existing medical condition. Therefore, the claim was billed 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 basic imaging services. You have been asked to pay a $40 copayment for the diagnostic mammography and diagnostic digital breast tomosynthesis. A diagnostic mammography and diagnostic digital breast tomosynthesis falls within the basic imaging 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 fora diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) provided on December 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
September 7, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that it was not your choice
to go to the emergency room after your dialysis. You say you were never charged before when you went to the
emergency room after dialysis. 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 $100
copayment for emergency care.
You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls
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 room visit provided on September 7, 2019.
Our decision is only about the September 7, 2019 service. If you have any questions about prior years billing,
please contact the plan directly.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiographic (ECG) recording up to 48 hours provided on May 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ECG recording up to 48 hours. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.
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 electrocardiographic (ECG) recording up to 48 hours provided on May 6, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair and accessories for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that the enrollee's mobility needs could be met with a lower level power wheelchair.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 these services. Our reviewer says that a Group 3 power wheelchair is not medically reasonable and necessary for the enrollee in this case. The enrollee had a stroke with left hemiparesis and dependent for mobility and ADLs. There is no documentation that the enrollee has pressure sores or is at high risk for pressure sores, has swelling of the legs and is unable to use manual elevating leg rests, that standard height arm rests will not meet the needs, that premade cushions will not meet the enrollee's needs. The enrollee's mobility needs can easily be met with a lower level power chair. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these items.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-approvea Group 3 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofprovider on October 28, 2019, and October 29, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-provider on October 28, 2019, and October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 9, 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 code 87798 is 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 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. We find that CPT code 87798 is not supported in the medical record. Specifically, the documentation does not indicate that amplified probe technique was utilized for infectious agent detection. 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 services rendered to the enrollee on October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eye surgery (67043 and 66984) provided on August 29, 2019.
You asked the Plan to pay for eye surgery provided in a different country. You say that this surgery was less expensive in the different country. The Plan denied your request. The Plan says non-emergent services outside of the United States are not covered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that any non-emergency care received outside of the United States and the U.S. Territories is not covered under any condition. We looked at this the file and Medicare rules. The record does not show that the services were emergent or urgent as they were not unforeseen. You elected to have these procedures done outside of the United States due to the cost. Based on this information, we decided that Medicare rules for coverage of eye surgery provided in another country have not been met. Therefore, we decided that the Plan does not have to pay for eye surgery (67043 and 66984) provided on August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Neck Blood Vessels (70498).
You asked the Plan to pre-approve The CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 The CT scan. Our reviewer says that rules for coverage have not been met. Our physician reviewer found there is no clinical rationale for the requested CT scan in the provided records. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Neck Blood Vessels (70498).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on June 9, 2019.
You asked the Plan to pay for moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on June 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe replacement of current spinal cord stimulator (SCS) with a BurstDR Stimulation System.You asked the Plan to pre-approvethe replacement of current spinal cord stimulator (SCS) with a BurstDR Stimulation System. You say that the replacement of the enrollee's current SCS with a BurstDR Stimulation System is medically necessary.The Plan denied your request. The Plan says the replacement of the enrollee's current SCS with a BurstDR Stimulation System 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 replacement of current spinal cord stimulator (SCS) with a BurstDR Stimulation System. Our reviewer says that the replacement of the enrollee's current SCS with a BurstDR Stimulation System is not medically necessary. Our physician reviewer found the enrollee is with lumbar Radiculopathy and Chronic pain syndrome. A Medtronic SCS was placed in 2019, but "has never provided adequate coverage for low back or hip pain." The proposed plan is an IPG exchange to the St. Jude Burst spinal cord stimulator. The documentation does not support that the replacement of the enrollee's Medtronic SCS with a Burst SCS would likely improve the enrollee's pain. The enrollee has a SCS system in place, and it has not resulted in significant pain relief for her. There are no clinical trials identified that demonstrate the superiority of the BurstDR Stimulation System compared to other SCS systems. The documentation does not support that SCS replacement is medically reasonable and necessary for the enrollee in this case.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 replacement of current spinal cord stimulator (SCS) with a BurstDR Stimulation System have not been met.Therefore, we decided that the Plan does not have to pre-approvethe replacement of current spinal cord stimulator (SCS) with a BurstDR Stimulation System.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care for cellulitis of the right lower leg on 3/23/20. The enrollee's prior level of function was independent in self-care and ambulation with a walker. His diabetes is noted controlled. His hypertension is controlled with oral Lasix and home lisinopril. He has a history of an old right lower extremity deep vein thrombosis. He is on Keflex for cellulitis and oral Lasix. He needs supervision for upper body dressing and oral hygiene. He needs maximum assistance for lower body dressing and putting on footwear. The enrollee needs minimal assistance for toilet transfers and moderate assistance for sit to stand. The enrollee ambulated with a rolling walker for 20 feet and 10 feet with minimal assist. A 3/25/20 physical therapy (PT) note states the enrollee ambulated 30 feet with bariatric rolling walker and close supervision. In occupational therapy (OT) the enrollee needed minimal assistance for toileting and grooming. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive IRF physician or nursing supervision. The enrollee may benefit and participate from multiple therapies such as PT and OT, however the documentation does not support that this enrollee's functional level requires an intensive rehabilitation therapy program provided in an IRF.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency department (ED) visit provided from October 23, 2019 to October 26, 2019. You asked the Plan to waive the copayment for the ED visit. You say that you were admitted to the hospital so the copayment should be waived. The Plan denied your request. The Plan says based on the documentation provided, the level of treatment was outpatient observation. Since you were not admitted as inpatient, coverage criteria has not been met.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 $75 copayment for emergency care.You have been asked to pay $75 for the ED visit. An ED visit falls 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 foran emergency department (ED) visit provided from October 23, 2019 to October 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on November 4, 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 code Q9967 is 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 Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. We find that CPT code Q9967 is not supported in the medical record. Specifically, the records do not support one unit of the billed code, as the records indicate that 64 ml of Isovue-370 was administered. 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 services rendered to the enrollee on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 5, 2019 to the enrollee 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 a non-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 referring provider 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 September 5, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transtibial and symes prosthesis coded as L5629, L5661, L5637 and L5940.
You asked the Plan to pre-approve transtibial and symes prosthesis. You say that you ask that the device in question be approved so that the enrollee's needed medical supply can be provided. The Plan denied your request. The Plan says the request for these components are not reasonable or necessary per Medicare guidelines.
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 transtibial and symes prosthesis. 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 a partial foot amputation. The enrollee does not have a below-the-knee amputation. The prosthesis is not medically needed and the criteria not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transtibial and symes prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve transtibial and symes prosthesis coded as L5629, L5661, L5637 and L5940.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI of the brain provided on August 7, 2019.
You asked the Plan to pay for the MRI of the brain. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an MRI of the brain provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up office visit provided on October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a follow-up office visit. You say that these services were needed. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network available to provide these services.
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 a follow-up office visit provided on October 17, 2019 by an out of network (OON) provider.