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

We decided that the Plan does not have to pay forthe drug testing rendered on December 18, 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 the claim was not billed correctly.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 claim for these services was billed with POS code 11 for an independent laboratory; however, the file shows that the specimen was not obtained in an independent laboratory.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on December 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visit and the
cystoscopy provided from March 17, 2020 to March 18, 2020.
You asked the Plan to waive the copayments for the emergency room visit and the cystoscopy. You say that
you were admitted as an inpatient and the copayments should be waived. 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 $120
copayment for emergency care and an $80 copayment for each outpatient surgery and/or services at an
ambulatory surgical center or outpatient hospital facility.
You have been asked to pay a $120 copayment for the emergency room visit and an $80 copayment for the
cystoscopy. The emergency room visit falls within the "Emergency care" benefit category. The cystoscopy
falls within the "Outpatient hospital services" benefit category. The medical record does not show you were
admitted as an inpatient, therefore, you were considered outpatient. 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 copayments for the emergency room visit and the cystoscopy provided
from March 17, 2020 to March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses, over the allowed amount, provided on March 6,
2020.
You asked the Plan to pay for eyeglasses over the allowed amount. You say that the provider told you that you
did not owe anything. The Plan denied your request. The Plan says your eyeglass claim was over the allowed
amount.
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. The Plan allowance for supplemental eyewear every year is $300. Members are responsible for all
costs over and above the allowance amount.
We looked at the file and the Plan's rules. The supplier charged $634.95. $334.95 is enrollee liability.
Therefore, we decided that the Plan does not have to pay for eyeglasses, over the allowed amount, provided on
March 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsuranceforthe outpatient services provided from December 4, 2019 through December 23, 2019.You asked the Plan to waive the coinsurance for the outpatient services. You asked for review of the charges.The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 50% coinsurance for provider and professional services at an out-of-network outpatient hospital, 50% coinsurance for radiation therapy at an out-of-network outpatient hospital and 20% coinsurance for Medicare Part B covered drugs from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 28, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on June 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on February 3, 2020.
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this code is not a valid code 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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of paroxysmal atrial fibrillation, implantable cardioverter-defibrillator (ICD) placement, non-ischemic cardiomyopathy, and NYSHA Class III congestive heart failure with reduced left ventricular ejection fraction. 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. The device is considered
experimental/investigational in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs HF System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 22, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat 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 a domiciliary, rest home visit provided on January 22, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on April 24, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that this copayment is a financial hardship. 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 $225 copayment per day, per provider, for in-network Medicare-covered diagnosticradiology services. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe CT scan provided on April 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora tissue graft (20926) provided on December 10, 2019.You asked the Plan to pay forthe tissue graft. You say that you would like reconsideration because the assistant at surgery may be paid for this CPT code.The Plan denied your request. The Plan says an assistant at surgery may not be paid for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 20926. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined thatan assistant surgeon is not medically necessary and will not be paid. Additionally, the assistant at surgeon is not a PA, NP or CNS. Based upon this information, we find that Medicare coverage criteria for the tissue graft have not been met.Therefore, we decided that the Plan does not have to pay fora tissue graft (20926) provided on December 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 12, 2020.You asked the Plan to waive the copayment for the ambulance transport. You say that you can't afford this. You say that you want insurance to pay more.The Plan denied your request. The Plan says the copayment 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 $300 copayment for each separate Medicare-covered, one-way, ambulance service.You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the "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 for the ambulance transport provided on March 12, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the requested shoulder surgery.
You asked the Plan to pre-approve the requested shoulder surgery. You say that the requested shoulder surgery
is medically necessary. The Plan denied your request. The Plan says that the requested shoulder surgery is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 requested shoulder surgery. Our
reviewer says that the requested shoulder surgery is medically necessary. Our physician reviewer found this
enrollee presents with a 6-week history of persistent right shoulder pain and weakness, status post a fall.
Functional limitations are noted in activities of daily living. Clinical exam findings have documented severe
loss of range of motion, positive impingement and rotator cuff provocative testing, and rotator cuff weakness.
There is imaging evidence of full thickness, full-width retracted rotator cuff tears, possible labral tear, large
joint effusion, and degenerative changes of the acromioclavicular joint. She had failed reasonable conservative
treatment including activity modification, medications, splinting, and physician-directed home exercise. Under
consideration is a request for right shoulder arthroscopic acromioplasty, distal clavicle excision, possible
rotator cuff repair, and possible biceps tenotomy versus tenodesis. Current evidence based medical literature
would support proceeding with right shoulder arthroscopic surgery as outlined. There is evidence of full
thickness, full-width retracted rotator cuff tears which would not be typically addressed with physical therapy
or injections. There is evidence of acromioclavicular joint degenerative changes and positive impingement
signs to support acromioplasty and distal clavicle excision. Occult biceps tears, incomplete and MRI-negative
are often confirmed at time of arthroscopic surgery. Given imaging evidence of labral pathology, biceps
tenodesis versus tenotomy is reasonable based on the discretion of the surgeon at the time of arthroscopic
evaluation and concomitant rotator cuff repair. Therefore, this request for right shoulder arthroscopic
acromioplasty, distal clavicle excision, possible rotator cuff repair, and possible biceps tenotomy versus
tenodesis is 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 requested shoulder surgery have been met. Therefore, we decided that the
Plan has to pre-approve the requested shoulder surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested IRF admission.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 enrollee does not meet criteria for the requested IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.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 notbeen met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met.
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 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
current medical status does not currently require intensive physician and nursing oversight only in an IRF. The
documentation does not support that the enrollee's functional status and his endurance level require 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare criteria for transfer are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The clinical assessment in the case file does not support that you are reasonably expected to benefit from, and improve with, LTACH services. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis at this time. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the inpatient stay provided from February 24,
2020 through February 27, 2020.
You asked the Plan to reduce the cost for the inpatient stay. You say that you were expecting to pay $750 and a
$50 copayment. You say that you were not expecting to pay an extra $300 in addition to your deductible. The
Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is your deductible is $750. This is the amount you have to pay out-ofpocket
before we will pay our share for your covered medical services. Until you have paid the deductible
amount, you must pay the full cost of your covered services. Your contract with the Plan says that you must
pay a $300 copayment per admission after the deductible is met for each medically necessary inpatient stay.
The item or service you asked the Plan to reduce the cost for falls within the "Inpatient hospital care" benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible
applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time
the inpatient stay was began on February 24, 2020. Therefore, $750 has been applied to meet your deductible.
Since the $750 deductible was met, you have also been asked to pay a $300 copayment for the inpatient stay.
The records show that you were admitted as an inpatient for three days. 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 reduce the
cost for the inpatient stay provided from February 24, 2020 through February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair chair lift.
You asked the Plan to pre-approve a stair chair lift. You say that the item is necessary. The Plan denied your
request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has
not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a stair chair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath/shower chair (E0240). You asked the Plan to pre-approve the bath/shower chair. You say that you cannot stand on your own.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve bath/shower chair (E0240).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 9, 2020 through February 13, 2020.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this infusion code is not for durable medical equipment and was not delivered to the member's home.The Plan denied your request. The Plan says Medicare uses another code for reporting of, and payment for these 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 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 the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on January 9, 2020 through February 13, 2020.