Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forbiopsy services provided on February 4, 2020.You asked the Plan to pay forthe surgery. You say that you would like reconsideration because this claim was billed correctly as there are no other indications listed.The Plan denied your request. The Plan says that another diagnosis code should be coded first for proper sequencing.The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have been met. Specifically, the record does not indicate that the rendering provider would have been aware of an underlying condition. The service rendered was diagnostic, therefore reporting of the underlying condition is not applicable in this case.Therefore, we decided that the Plan has to pay forbiopsy services provided on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forultrasound guidance for vascular access (76937) provided on February 5, 2020.You asked the Plan to pay forthe ultrasound guidance. You say that you would like reconsideration because this service was billed with a primary code that has already been paid.The Plan denied your request. The Plan says CPT code 96937 was billed without the appropriate primary code.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, we have confirmed that code 76937 is a type II add-on code. This means that the contractor defines the appropriate primary codes for this service. The record indicates that the primary code billed is not appropriate. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forultrasound guidance for vascular access (76937) provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 16, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that 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 laboratory services provided on September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on January 6, 2020.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that 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 $300 copayment for emergency ambulance services and non-emergency ambulance services. You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the emergency ambulance services and non-emergency ambulance 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 forthe ambulance transport provided on January 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance response services should be covered. You say that the Plan should issue payment to the provider. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 27, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe care needed is not complex enough, and can be provided at a lower level of care.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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable, with no evidence of a need for supervision by a PMY physician. There is no need for acute rehab nursing care. You may benefit from further PT and OT, but you do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status, fatigue, and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) services.You asked the Plan to pre-approvethe MRI services. You say that the records provided support the need for an MRI.The Plan denied your request. The Plan says the requested MRI is not medically necessary under Medicare guidelines.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 the MRI services. Our reviewer says that an MRI is not medically reasonable and necessary. Our physician reviewer found the enrollee reports a twisting injury of his ankle. Imaging in the emergency department was negative for an acute fracture on May 8, 2020. The enrollee communicated telephonically with his primary care provider office on May 14, 2020. He reported ongoing pain and swelling. Documentation notes a plan for a magnetic imaging study and referral to orthopedic specialists. There is no documented communication between the provider and the patient, only with nursing. There is no detailed ongoing assessment of history, differential diagnosis, or conservative care. Without the support of the documentation, medical necessity cannot be determined.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 MRI services have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit rendered on July 17, 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 99349 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 99349 is Level 3 home visit for the evaluation and management of established patient with problem of moderate to high severity, including detailed interval history and medical decision making of moderate complexity, typical time with patient 40 minutes.We find that CPT code 99349 is not supported in the medical record. Specifically, the documentation shows that the services were performed by a registered nurse (RN). Code 99349 is for services performed by a physician, physician's assistant, or nurse practitioner only. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided thatthe Plan does not have to pay forthe home visit rendered on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe perfusionist services provided on July 31, 2019.You asked the Plan to pay forthe services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. The service at issuewas provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay forthe perfusionist services provided on July 31, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for CPT code 14301 provided on December 17, 2019.
You asked the Plan to pay for CPT code 14301. You say that the medical records support the billing of CPT
code 14301. The Plan denied your request. The Plan says that the medical records do not support the billing of
CPT code 14301.
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 14301 is Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.
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 CPT code 14301. Our reviewer says that the
medical records support the billing of CPT code 14301. Our physician reviewer found the enrollee has a
diagnosis of Malignant neoplasm of central portion of left female breast. On 12/17/19, the enrollee underwent
Wire localization left breast with lumpectomy, quadrnatectomy through a V-plasty with oncoplastic closure,
and placement of BioZorb tumor marker, and sentinel node biopsy. The Operative Report contains the
following: "We incised with a V-plasty at 9 o'clock...", "...raising flaps superiorly, inferiorly, and medially", "In
order to close the cavity and minimize any indentation or defect, a tissue transfer procedure was performed. We
raised flaps circumferentially with electrocautery of about 40 square centimeters total", "We then brought the
layers back together with 3-0 Vicryl."
The documentation supports that there was adjacent tissue transfer during the surgery that met the billing of
CPT code 14301.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT code 14301 have been met. Therefore, we decided that the Plan has to pay
for CPT code 14301 provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on November 19,
2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you received services in a doctors
office and disagree with the surgical 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 $290
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
The record shows that you received arthrocentesis on November 19, 2019 in an outpatient hospital facility.
Arthrocentesis is considered a surgical procedure. Therefore, you are responsible to pay the allowed amount of
$265.95, which is less than the $290 copayment.
You have been asked to pay $265.95 for arthrocentesis. Arthrocentesis 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 arthrocentesis provided on November 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on September 13, 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 48146 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 48146 is pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure).We find that CPT code 48146 is not supported in the medical record. Specifically, there is no documentation that a near-total distal pancreatectomy was performed withpreservation of the duodenum. 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 surgical services rendered on September 13, 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
December 27, 2018 to February 15, 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 billed claim is for a non-participating provider, and the appropriate home health data Bill of
Type was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed correctly.
These services were not billed with the correct Type of Bill. 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 home health services provided to the enrollee from December 27, 2018 to February 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on October 1, 2019.You asked the Plan to pay fortrain 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 intraoperative 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 fortrain of four testing (95999) provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox Injections (J0585).
You asked the Plan to pre-approve the botox injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the botox injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found review of Medicare criteria and compendia do not support the use of Botox for the enrollee's medical condition. The enrollee's diagnosis is not a covered diagnosis. 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 botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox Injections (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compression stockings identified with code E1399 that were issued on December 3, 2019.You asked the Plan to pay forthe compression stockings. You say that you need the stockings for treatment of varicose veins.The Plan denied your request. The Plan says the stockings are a noncovered benefit because they do not meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe compression stockings identified with code E1399 that were issued on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forfundus photography with interpretation and report (92250) and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014) provided on January 30, 2020.You asked the Plan to waive the copayment forthe medical eye examination. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the provider billed for a medical examination, not routine. You are asked to pay a $35 copayment for the medical eye exam. 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 forfundus photography with interpretation and report (92250) and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014) provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgeon services to be provided by the requested provider.
You asked the Plan to pre-approve the oral surgeon services. The Plan denied your request. The Plan says you must receive care from a network provider and in most cases, care received from an out-of-network provider will not be covered, except for emergency care or urgently needed service and needed medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve oral surgeon services to be provided by the requested provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction provided on January 7, 2020 by an out-of-network provider.You asked the Plan to pay forthe eye refraction. You say that the provider is in-network.The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Refractive services are not covered under your benefit plan unless rendered by a Routine Vision Care Provider found in the Routine Vision Care section of the Plan's Provider Directory. If your provider is a part of the Routine Vision Care provider network, then the claim for your refraction has been misfiled and your provider may refile it to the appropriate vision vendor.Therefore, we decided that the Plan does not have to pay forthe eye refraction provided on January 7, 2020 by an out-of-network provider.