Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foralumbar-sacral orthosis (L0650), a wrist-hand orthosis (L3916), and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 24, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA)or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650), a wrist-hand orthosis (L3916), and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy (PT) (97116, 97110) provided on October 9, 2019.
You asked the Plan to waive the copayment for PT. You say that the claim should not be paid as the provider just "looked you over" and did not provide any services. The Plan denied your request. The Plan says outpatient rehabilitation services, including physical therapy, have a $40 copayment.
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 outpatient rehabilitation services, including physical therapy. You have been asked to pay a $40 copayment for PT. This service falls within the outpatient rehabilitation services benefit category. The record shows that you were treated for a Berg Assessment. This assessment checks if you have the ability or inability to take care of yourself after surgery. 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 physical therapy (PT) (97116, 97110) provided on October 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left lumbar interbody fusion L2-3 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 medical necessity has not been established, as there is no documented evidence of smoking cessation for at least six weeks prior to the planned procedure.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 there is no documentation that the enrollee has stopped smoking. Spine fusion surgery is contraindicated in current smokers.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 left lumbar interbody fusion L2-3 for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveCT scan of the abdomen and pelvis for the enrollee.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says that the services were not considered medically necessary.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 wascorrect in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the imaging characteristics described in the left adrenal gland are almost always associated with a non-functioning adenoma. The lesion however exceeds 2.0 cm in diameter and has not been evaluated for size after the initial MRI. Given the size most protocols will allow for a one year follow-up as a precaution and such surveillance has not been done in this case. For this reason, CT should be approved.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 scan have been met.Therefore, we decided thatthe Plan has to pre-approveCT scan of the abdomen and pelvis for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the cervical spine for the enrollee.
You asked the Plan to pre-approve the enrollee. You say that this is medically necessary. The Plan denied your request. The Plan says that MRI is the test of choice for spinal imaging indications.
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 enrollee. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found it is true that MRI is the usual test for evaluation of the cervical spinal canal however in cases where there is suspected bone destruction on other imaging CT is commonly done due to the bone detail which is offered by this technology versus MRI which is better for soft tissues such as disc disease and the spinal cord. 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 enrollee have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the cervical spine for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan 50 MG tablets.
You asked the Plan to pre-approve Xifaxan tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Xifaxan tablets are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan 50 MG tablets.
Benefits for Xifaxan tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 13, 2018.
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 not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until November 14, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on August 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three custom fabricated abutments - includes placement and three abutment supported porcelain fused to metal crowns provided on September 10, 2019.
You asked the Plan to pay for the custom fabricated abutments and abutment supported crowns. You say that your plan covers crowns and you were told before you went that crowns were covered. You also say that you were told before you went that this was a valid in-network provider. The Plan denied your request. The Plan says these services are not covered under the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three custom fabricated abutments - includes placement and three abutment supported porcelain fused to metal crowns provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on October 15,
2019.
You asked the Plan to waive the copayment for the arthrocentesis. You say that your office visit was
improperly coded as a surgical procedure. You say that this should be recoded. 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 $150
copayment for Medicare-covered outpatient hospital surgery services.
You have been asked to pay a $150 copayment for the arthrocentesis. The arthrocentesis falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show that the arthrocentesis was performed during the office visit, which
is considered a surgical procedure. 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 arthrocentesis
provided on October 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial colectomy (44143), an exclusion of the small intestine (44700), a proctosigmoidoscopy (45300), and a salpingo-oophorectomy (58720) provided on February 5, 2019.
You asked the Plan to pay for a partial colectomy, an exclusion of the small intestine, a proctosigmoidoscopy, and a salpingo-oophorectomy. You say that these codes should be paid. The Plan denied your request. The Plan says these codes are 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 44143 is colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure); 44700 is exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum); and 45300: proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). 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 a partial colectomy, an exclusion of the
small intestine, a proctosigmoidoscopy, and a salpingo-oophorectomy. Our reviewer says that the use of 44143 is not supported by the medical records. The enrollee did not undergo partial colectomy, with end colostomy and closure of the distal segment. Rather, a takedown (or reversal) of the previous Hartmann procedure was performed. Other CPT codes are available for the procedure that was performed. The documentation also does not support the use of 44700, as the documentation does not support exclusion of the small intestine from the pelvis by mesh or other prosthesis or native tissue. The documentation does not support the use of 45300, a diagnostic rigid proctosigmoidoscopy. CPT code 58720 has a bundled relationship with code 44005, which was billed on the same claim for the same date of service, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 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 a partial colectomy, an exclusion of the small intestine, a proctosigmoidoscopy, and a salpingo-oophorectomy have not been met. Therefore, we decided that the Plan does not have to pay for a partial colectomy (44143), an exclusion of the small intestine (44700), a proctosigmoidoscopy (45300), and a salpingo-oophorectomy (58720) provided on February 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the services could be provided in another setting.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. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for CHF. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on June 4, 2019 by the out of network provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 psychotherapy services provided on June 4, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot walk or take care of herself. The Plan denied your request. The Plan says that the enrollee does not require an inpatient level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 18, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiography provided on September 5, 2019.You asked the Plan to waive the copayment forthe echocardiography. You say that you don't understand the difference in the bill and Plan report.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 $40 copayment for in-network diagnostic procedures and tests. You have been asked to pay a $40 copayment for the echocardiography. The echocardiography 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 agreedto pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe echocardiography provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 9, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on April 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment forthe diagnostic examination and refraction services (92014) provided September 9, 2019.You asked the Plan to waive the deductible and copayment forthe vision services. You say that you went in for a routine eye exam and now you're being told this was a medical check-up and not covered.The Plan denied your request. The Plan says the deductible and copayment has been 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 an $80 and a $50 copayment for in-network Medicare covered exam to diagnose and treat diseases or conditions of the eye. The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category Vision care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $80 deductible and a $50 copayment. The plan applied $43.20 deductible and $50 for the diagnostic vision services. This cost sharing is a contractual obligation that had not beenmet at the time that the vision services was received on September 9, 2019. Therefore, we decided that the Plan does not have to waive the deductible and copayment for the diagnostic examination and refraction services (92014) provided September 9, 2019.