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

We decided that the Plan has to pay for CPT code 93971 provided on June 30, 2019.
You asked the Plan to pay for CPT code 93971. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the service is not covered based on the submitted diagnosis codes.
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 is denying payment for CPT code 93971 due to the submitted diagnosis codes. The Plan uses Local Coverage Article A56914 as the basis for their denial; however, there is no such article for the date of service at issue. We find that the Plan has not substantiated their reasoning for denial in this case. Therefore, we decided that the Plan has to pay for CPT code 93971 provided on June 30, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 2, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the
provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral
orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral
orthosis provided on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hearing aids (V5261, V5160) provided November 12, 2019. 
 
You asked the Plan to waive the coinsurance for the hearing aids. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan coverage for hearing aids assesses a 40% coinsurance for hearing aids provided out-of-network. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the correct coinsurance was applied. Therefore, we decided that the Plan does not have to waive the coinsurance for hearing aids (V5261, V5160) provided November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insertion or replacement of a spinal
neurostimulator provided on November 27, 2019.
You asked the Plan to waive the coinsurance for the insertion or replacement of a spinal neurostimulator. You
say that you did not receive the service you are being billed for. 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 each covered surgery or observation service provided in an outpatient hospital facility.
The medical records show that you received the insertion or replacement of a spinal neurostimulator on
November 27, 2019. The allowed amount is $27,683.41 and 20% of that is $5,536.68.
You have been asked to pay the total coinsurance amount of $5,536.68 for the insertion or replacement of a
spinal neurostimulator. The insertion or replacement of a spinal neurostimulator 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 coinsurance for the insertion or replacement of a spinal
neurostimulator provided on November 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular stress tests and artery scan rendered on
December 11, 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 the claim was billed with the wrong POS code.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The provider billed the claim for these services with POS code 21 for
an inpatient hospital; however, the file shows that these services were not performed in an inpatient hospital
setting. The Plan is requesting a corrected claim from the provider. Therefore, we decided that the Plan does
not have to pay for the cardiovascular stress tests and artery scan rendered on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a tendon sheath injection provided on May 28, 2019.
You asked the Plan to waive the copayment for a tendon sheath injection. You say that you feel that you should only owe a $50 copayment. 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 $300 copayment for each outpatient surgery service provided in an outpatient hospital facility. You have been asked to pay the allowed amount of $246.17, which is less than the $300 copayment for a tendon sheath injection. A tendon sheath injection 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 tendon sheath injection provided on May 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit on December 5, 2019. 
 
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 an $80 copayment for Emergency Care.  
 
You have been asked to pay an $80 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 an Emergency Room visit on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 10, 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-network provider on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9328) services provided from November 5, 2019 to December 12, 2019.
You asked the Plan to pay for the home infusion therapy 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 are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file, Medicare rules and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) services provided from November 5, 2019 to December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex. 
 
You asked the Plan to pre-approve Gamunex. 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 follows Medicare rules. Medicare rules say that Gamunex is only covered for certain indications. 
 
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 Gamunex. Our reviewer says that the requested Gamunex infusions are not medically reasonable or necessary. Our physician reviewer found the enrollee prostate cancer and chronic lymphocytic leukemia and low gammaglobulin levels; there is concern for increased risk of infection. Based on the medical records provided, there is insufficient evidence that the enrollee has a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of Gamunex. The provided records do not report a recent history of serious bacterial infection(s) requiring either oral or parenteral antibiotic therapy. 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 Gamunex have not been met. Therefore, we decided that the Plan does not have to pre-approve Gamunex.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on February 27, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied
your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code
95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not
a separately reportable procedure and is included in the other interoperative neuromonitoring procedures.
Based on this information, we decided that Medicare rules for coverage of train of four testing have not been
met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on
February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the debridement services you received from October 1, 2019 to October 29, 2019. 
 
You asked the Plan to waive the copays for the services provided. You say that you weren't aware that your responsibility was going to be so high. The Plan denied your request. The Plan says cost shares are a contractual obligation and cannot be waived. 
 
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 $295 copay for outpatient surgery and other medical services provided at hospital outpatient facilities.  
 
You have been asked to pay a $295 copay for each date of service provided. The services fall within the outpatient surgery 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 copays for the debridement services you received from October 1, 2019 to October 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October 2, 2019 to October 8, 2019.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says the claim was submitted with an inappropriate "Type of Bill" code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim summited cannot be paid due to the "Type of Bill" or "Bill Type Code" provided. The Bill Type Code reported was 324, the code expected by Medicare is 329. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from October 2, 2019 to October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99203) provided on November 11, 2019. 
 
You asked the Plan to pay for a chiropractic office. You say that you did not have to pay for services from your previous chiropractor. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
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 a chiropractic office visit (99203) provided on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed rails. 
 
You asked the Plan to pre-approve bed rails. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that bed rails are only covered when they are an integral part of, or an accessory to a covered hospital bed. 
 
We looked at the file and Medicare rules. Review of the file does not support that you have been approved for a covered hospital bed. Based on this information, we decided that Medicare rules for coverage of bed rails have not been met. Therefore, we decided that the Plan does not have to pre-approve bed rails.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 21, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says prior authorization was not 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 fromout-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 Plandid not pre-approve the drug test. 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 a drug test provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 7, 2019 by a non-participating 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-participating 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 August 7, 2019 by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary artery sensor for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this device is considered experimental and investigational. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore 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. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve transcatheter implantation of a wireless pulmonary artery sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the cervical collar provided on
September 20, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648) and the cervical collar (L0180). You say that
the orthoses were medically necessary. The Plan denied your request. The Plan says the records do not contain
a face-to-face encounter supporting that the enrollee was evaluated or treated for a condition that supports the
orthoses.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthoses. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral
orthosis (L0648) and the cervical collar (L0180) have not been met. Therefore, we decided that the Plan does
not have to pay for the lumbar-sacral orthosis and the cervical collar provided on September 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a laparoscopy provided on December 11,
2019.
You asked the Plan to waive the coinsurance for a laparoscopy. You say that you 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 20%
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received a laparoscopy on December 11, 2019. The allowed amount is $738.02 and 20% of that is
$147.60.
You have been asked to pay the total coinsurance amount of $147.60 for a laparoscopy. A laparoscopy falls
within the outpatient surgery and other medical 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 coinsurance for a
laparoscopy provided on December 11, 2019.