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

We decided that the Plan does not have to pay for physician's services provided on September 26, 2019.
You asked the Plan to pay for the physician's 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 physician's services provided on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 12, 2019 through October 15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 12, 2019 through October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter (E1230).
You asked the Plan to pre-approve the electric scooter. You say that you have difficulty walking secondary to a prolapsed bladder, and you intend to use the scooter around your house and not just for outdoor use. The Plan denied your request. The Plan says you do not meet the criteria for coverage of an electric scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The rules also say that Medicare will pay for durable medical equipment that is needed for use in the home. The file shows that you are able to operate a manual wheelchair, you are independent with gait and transfers in the home with a four-wheeled walker, and you require the scooter only to go to the store. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric scooter (E1230).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac
contractility modulation system, including contractility evaluation when performed, and programming of
sensing and therapeutic parameters; pulse generator with transvenous electrodes (CPT Code 0408T), for the
enrollee.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says the enrollee's condition does not meet the rules for approval
because this represents a non-covered service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. This is a non-covered service.
Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of permanent cardiac
contractility modulation system, including contractility evaluation when performed, and programming of
sensing and therapeutic parameters; pulse generator with transvenous electrodes (CPT Code 0408T), for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and the topical application of fluoride varnish (D1206) provided on February 14, 2019.
You asked the Plan to pay for the dental services. You say that you were advised that the services would be covered. The Plan denied your request. The Plan says the bitewing x-rays and topical application of fluoride varnish are not listed as covered services.
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 bitewing x-rays and the topical application of fluoride varnish are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and the topical application of fluoride varnish (D1206) provided on February 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on October 22, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that you would like the laboratory services to be covered as a part of your wellness visit. 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 inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each Medicare-covered laboratory test. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient tests and therapeutic services and supplies" category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 laboratory work provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from September 1, 2019 through September 6, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have beenmet.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from September 1, 2019 through September 6, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open acase 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 pre-approveOne Touch Verio test strips.You asked the Plan to pre-approvea non-preferred brand of test strips. You say that the enrollee wants to continue with the One Touch Veriotest strips.The Plan denied your request. The Plan says there are no medical records to show the reason for using this brand of strip.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at review the file and Medicare rules. The authorization request states that the non-preferred test strips are notmedically necessary for the enrollee. Based on this information, we decided that Medicare rules for coverage of a non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOne Touch Verio test strips
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on an excision procedure (11400) provided on August 15, 2019.You asked the Plan to pay forsurgical assistant services. You say that these services were medically necessary.The Plan denied your request. The Plan says surgical assistant services are not covered 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 11400. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met.Therefore, we decided that the Plan does not have to pay forsurgical assistant services on an excision procedure (11400) provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that due to finances the enrollee cannot afford to purchase the garments on her own and you feel it is medically necessary that the enrollee uses them several times a day.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (CPT Code E1390RR) provided on June 10, 2019, by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. 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 2019 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 you received an oxygen concentrator (CPT Code E1390RR) provided on June 10, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 oxygen concentrator (CPT Code E1390RR) provided on June 10, 2019, by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 5, 2019 through October 14, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you feel this stay was connected to a previous inpatient stay. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 you received inpatient hospital care from October 5, 2019 through October 14, 2019. You are asked to pay a $425 copayment per admission for inpatient hospital care. 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 inpatient hospital care from October 5, 2019 through October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 50432) provided on July 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is included as part of the global surgical package.The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures with a global surgical package includes payment for the aboveservices related to the surgery when furnished by the physician who performs the surgery.We looked at the file and Medicare rules.The requested services are included as part of the global surgical package for CPT 36558, which was performed on July 9, 2019. CPT 36558 has a global surgical indicator of 010. As the requested services were provided within 10 days of the global surgery procedure, payment is included in the payment for CPT 36558.Based on this information, we decided that Medicare rules for coverage of CPT 50432have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 50432) provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 3, 2019.You asked the Plan to pay for the physician's services. The Plan deniedyour 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 Planhas 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 providerwith 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 physician's services provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low-level laser treatment (S8948), ultrasound therapy
(97035), and neuromuscular re-education (97112) with the physician.
You asked the Plan to pre-approve these services. You say that you are requesting reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the services requested are not a covered benefit under your
contractual policy.
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. Additionally, Medicare only covers therapy services
when provided by Licensed therapy professionals.
The records show that the services at issue are not manual manipulation of the spine. Additionally, you have
requested therapy services to be provided by a chiropractic neurologist. These services are not covered by
Medicare or by your health plan. Specifically, Medicare only covers therapy services when provided by a
Licensed therapy professional. The requested provider in this case is not a licensed therapy professional.
Therefore, we decided that the Plan does not have to pre-approve low-level laser treatment (S8948), ultrasound
therapy (97035), and neuromuscular re-education (97112).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (CPT Code E1390RR) provided on April 10, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. 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 2019 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 you received an oxygen concentrator (CPT Code E1390RR) provided on April 10, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 oxygen concentrator (CPT Code E1390RR) provided on April 10, 2019 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePrecision QID test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the enrollee wants to continue using the Precision QID test strips.The Plan denied your request. The Plan says there is no medical reason the enrollee is unable to use the preferred test strips.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. There is no documentation of medical necessity to use the non-preferred brand. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approvePrecision QID test strips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on June 13, 2019.You asked the Plan to pay for neuromuscular junction testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support that CPT code 95937 was performed.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 95937 is neuromuscular junction testing.We asked our coder 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 neuromuscular junction testing. Our reviewer says that the billing of CPT 95937 is not supported. Our reviewer found there is no evidence that the enrollee underwent neuromuscular junction testing for the purpose of diagnosing a neuromuscular junction disorder such as myasthenia gravis or botulinum toxicity.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on June 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography of the heart with quantitative evaluation of coronary calcium (75571).
You asked the Plan to pre-approve computed tomography of the heart. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is asymptomatic.
The Plan follows Medicare rules. Medicare rules say that Medicare does not cover a screening CCTA for asymptomatic patients. 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 computed tomography of the heart. Our reviewer says that this is not medically necessary at this time. Our physician reviewer found based on the records submitted, the enrollee has some coronary risk but no documented cardiac symptoms and a normal cardiovascular physical exam. In this case, since the enrollee has no documented cardiac symptoms or discordant stress test results, coverage criteria for cardiac CT scanning are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of computed tomography of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography of the heart with quantitative evaluation of coronary calcium (75571).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on January 15, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on January 15, 2019.