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

We decided that the Plan does not have to pay for colorectal cancer screening (HCPCS G0328) provided to the enrollee on August 12, 2019.You asked the Plan to pay for the screening. You say that this should be paid for.The Plandenied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0328 QW (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of HCPCS code G0328 is "colorectal cancer screening; fecal occult blood test, immunoassay, one to three simultaneous determinations; subcutaneous or intramuscular."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 the screening. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the documentation vaguely suggests that a rectal exam was performed and that that exam did not reveal any blood. However, it is unclear if this was an absence of gross blood or an absence of blood on stool guaiac/fecal occult blood testing. Therefore, the billing of G0328 is not supported.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 screening have not been met.Therefore, we decided that the Plan does not have to pay for colorectal cancer screening (HCPCS G0328) provided to the enrollee on August 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you have been seeing this doctor for years. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0667, E0652).
You asked the Plan to pre-approve the pneumatic compression device. You say that the pneumatic compression device is medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 pneumatic compression device. Our reviewer says that the pneumatic compression device requested in this case does not meet coverage criteria. Our physician reviewer found based on the medical records provided there is not adequate documentation to support use of the device. The records do not report measurements for both legs before and after treatment with the device. These measurements are required as part of the general coverage criteria.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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0667, E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5212).
You asked the Plan to pre-approve the lower partial denture. You say that the enrollee has multiple teeth missing. You say that the enrollee has remaining teeth in both arches that can support maxillary and mandibular partial dentures. You also say that the enrollee needs maxillary and mandibular partial dentures so she can eat properly. The Plan denied your request. The Plan says partial dentures are covered once every 60 months. The Plan also says that the benefit limit has been reached.
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 and dentures are a covered service, the benefit limit has been reached. The record shows that the Plan previously paid for a lower partial denture that you received on May 1, 2015. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 21, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was you annual wellness visit and you did not discuss any conditions. 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 $10 copayment for physician/practitioner services, including doctor's office visits. The medical records show that you received services beyond an annual wellness visit on November 21, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on November 21, 2019.
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.

You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets IRF admission criteria according to Medicare guidelines. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require treatment by multiple therapies, including physical therapy and occupational therapy, however these services are not needed in an IRF setting. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The enrollee's rehabilitation needs can be met at a lower intensity setting such as in a skilled nursing facility.

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.
Appeal type: Surgery
Decision: Unfavorable

e decided that the Plan does not have to reduce the copayments forthe upper gastrointestinal GI endoscopies provided on February 5, 2019 and October 22, 2019.You asked the Plan to reduce the copayments forthe upper GI endoscopies. You say that you are appealing because the claims were billed incorrectly. 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 $200 copayment per date of services at an ambulatory surgical center. You have been asked to pay a $200 copayment for each of the upper GI endoscopies. The upper GI endoscopies fall 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 reduce the copayments forthe upper GI endoscopies provided on February 5, 2019 and October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivoplasty to allow access for restorative procedure (D4212) for teeth # 8 and 9 and core build up (D2950) for teeth # 8 and 9.You asked the Plan to pre-approvea gingivoplasty and core build up. You say that the enrollee has severe discomfort with the amount of abrasion and abfraction that is present on tooth # 8. You say that this is a result of malocclusion and years of wear and tear. You also say that tooth # 8 should be approved for crown work.The Plan denied your request. The Plan says gingivoplastyis not listed as a covered service. The Plan also says core build up is not listed as a covered service.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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea gingivoplasty to allow access for restorative procedure (D4212) for teeth # 8 and 9 and core build up (D2950) for teeth # 8 and 9
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a visual field assessment for enrollee.You asked the Plan to pre-approve a visual field assessment. You say that the requested service allows for more timely and effective treatment.The Plan denied your request. The Plan says the service is 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 looked at the file, and Medicare rules. Based on the information provided, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a visual field assessment for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous insertion of a gastrostomy tube (49440) provided on June 20, 2019.
You asked the Plan to pay for the percutaneous insertion of a gastrostomy tube. You say that this should be processed and paid. The Plan denied your request. The Plan says this code is not supported in the documentation.
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 49440 is insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. 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 the percutaneous insertion of a gastrostomy tube. Our reviewer says that the billing of CPT 49440 is not supported by the medical records. Our physician reviewer found while a gastrostomy tube was placed in this enrollee, it was placed via an open procedure, not a percutaneous procedure. Therefore, CPT 49440 is not the correct code for the service performed. 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 percutaneous insertion of a gastrostomy tube have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous insertion of a gastrostomy tube (49440) provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services provided on October 19, 2019.You asked the Plan to waive the copayment forthe laboratory services. You say that you cannot afford this expense. 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 $35 copayment for laboratory services at an in-network outpatient hospital. You have been asked to pay a $35 copayment for the laboratory services. The laboratory services fall 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 laboratory services provided on October 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the nerve injection provided on September 6, 2019.
You asked the Plan to reduce the copayment for the nerve injection. You say that you had a procedure and not a surgery. You say your copayment should be $100 and not $350. 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 $350 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $350 copayment for the nerve injection. The nerve injection falls within the "Outpatient Surgery and Other Medical Services" benefit category. The record shows the nerve injection 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 reduce the copayment for the nerve injection provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient visits for acupuncture.
You asked the Plan to pre-approve acupuncture. You say that you feel that these services are needed for pain in
your lower legs and feet due to neuropathy. The Plan denied your request. The Plan says the requested service
is not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve outpatient visits for acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compression and supplies provided by out of network provider on December 3, 2019.
You asked the Plan to pay for the nebulizer with compression and supplies. You say that the ordering provider felt the nebulizer was medically necessary for the enrollee. The Plan denied your request. The Plan says you did not request 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 care that cannot be provided by network providers. The 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. 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 nebulizer with compression and supplies provided by out of network provider on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to hold you harmless for orthoses replacement parts provided to the enrollee on August 24, 2018.
You asked the Plan to hold you harmless for durable medical equipment. You say that you should not have to pay for the replacement parts. The Plan denied your request. The Plan says that the expense for the repairs is greater than the expense for the replacement.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. You were referred for durable medical equipment. The file does not show a notice that durable medical equipment would not be covered. Under Medicare rules, this means durable medical equipment is considered approved. Therefore, we decided that the Plan has to hold you harmless for orthoses replacement parts provided to the enrollee on August 24, 2018.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 1, 2019 through October 3, 2019 and the ambulance transport provided on October 3, 2019. You asked the Plan to waive the copayment for the inpatient stay and ambulance transport. You say that they didn't do much for you. You say that you can't pay these bills. The Plan denied your request. The Plan says the copayments 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 $180 each day for days 1-7 of a covered inpatient stay during a benefit period and a $185 for a Medicare-covered one-way trip. You have been asked to pay a total of $545 for the inpatient stay and ambulance transport. The inpatient stay falls within the "Inpatient hospital care" benefit category. 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 inpatient stay provided from October 1, 2019 through October 3, 2019 and the ambulance transport provided on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 20, 2019 through June 22, 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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found at the time of admission, there was no clear acute condition which remained which would require at least a total of two midnights of acute care services to justify admission. As blood pressure was controlled relatively quickly, the appropriate next step would have been continued observation care, then discharge home with close outpatient follow-up. 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 20, 2019 through June 22, 2019.