Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance applied to an ultrasound provided on November 17, 2019.
You asked the Plan to waive the coinsurance applied to the ultrasound. You say that you should not be charged separately for this amount because the ultrasound was done in the hospital after you had left the emergency room and were admitted to a room. You say that the ultrasound was done while you were in your bed in the room of the hospital on November 17, 2019. The Plan denied your request. The Plan says the coinsurance in dispute was appropriately applied to the service provided.
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 20% coinsurance for Outpatient Diagnostic Radiology Services. You have been asked to pay a 20% coinsurance for the ultrasound. The records show that the ultrasound in dispute was supplied to you at 9:30 am on November 17, 2020. The records show this this was during a time that you were still under and observation level of care and considered outpatient. The records show that you were not admitted as inpatient until 4:00 pm on November 17, 2020. The ultrasound falls within the Outpatient Diagnostic Radiology 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 coinsurance applied to an ultrasound provided on November 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered on August 14, 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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered for specific indications. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant melanoma of other part of the trunk. The melanoma was a superficial spreading type, was on the enrollee's back, and was invasive to a depth of 0.76 mm, pathologic stage pT1a, pNx, pMx. The documentation does not support a diagnosis of a T1a tumor with significant uncertainty about the adequacy of microstaging (positive deep margin), or a T1b or T2 tumor; therefore, the testing was not reasonable or 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 pay for the DecisionDx-Melanoma testing rendered on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on September 30, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by 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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 15-21 drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray coded 72020 provided on July 10, 2019.You asked the Plan to pay forthe x-ray. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are a duplicateclaim.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 72020 is radiologic examination, spine, single view, specify level.We find that CPT code 72020 is not supported in the medical record. Specifically, this claim is a duplicate to another claim with the same CPT code that was previously processed by the plan. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray coded 72020 provided on July 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from September 12, 2019 to September 30, 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 the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered with code 85. We looked at the file and Medicare rules. The claims were not billed with the required FIPS code. 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 home health services rendered from September 12, 2019 to September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you falling and not being able to get up is an emergency situation. You say that you were told by the 911 operator that an ambulance would come and help you. You stated that the claims should be covered. You say that just because you were not taken to an emergency room does not make it less of an emergency.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 29, 2019 and December 7, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you cannot always call to make sure you have prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained.
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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0481 provided on November 14, 2019.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Planmust 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 G0481 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed.We find that CPT code G0481 is not supported in the medical record. Specifically, the maximum allowed amount for this code for a single date of service is 1 unit. This code was already reported and processed on another claim for this date of service. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0481 provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an emergency department visit (99285), observation care, and related services (96360, 96361, 36415, 80053, 82010, 83735, 85025, 81001, 71045, 93005, G0378) provided from November 13, 2019 to November 15, 2019.
You asked the Plan to pay for an emergency department visit, observation care, and related services. You say that you were told these services did not require authorization. The Plan denied your request. The Plan says that these services were not authorized.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say that a Medicare plan must pay for emergency care regardless of whether the care is provided by a contract provider or a non-contract provider. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that these services were denied for no authorization. However, authorization is not required for emergency services. The Plan has also not provided medical records or other information used in their decision to partially overturn these services. Therefore, we decided that the Plan has to pay for an emergency department visit (99285), observation care, and related services (96360, 96361, 36415, 80053, 82010, 83735, 85025, 81001, 71045, 93005, G0378) provided from November 13, 2019 to November 15, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing coded 81479 provided on August 20,
2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory testing coded 81479 provided on August 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that you need therapy to help you walk. The Plan denied your request. The Plan says there is insufficient documentation to make an accurate assessment of your needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We looked at the file, and Medicare rules. In this case, there were insufficient records provided to show that the requested services are medically necessary for a specific treatment strategy. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora CT Scan of the abdomen (74170) provided on December 10, 2019.You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim has been billed with an incorrect place of service code.The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan have not been met. Specifically, the record indicates that this member was inpatient status on this date of service. The submitted claim includes an outpatient place of service code.Therefore, we decided that the Plan does not have to pay fora CT Scan of the abdomen (74170) provided on December 10, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered on October 21, 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 the services are not covered.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 forthe outpatient mental health services rendered on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from January 21, 2020 to January 29, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services were 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 records show that you presented to the emergency department (ED) with shortness of breath. You were admitted with a diagnosis of congestive heart failure. A computed tomography (CT) scan showed a small pleural effusion (water in the lungs). The records support that, at the time of the admission, the admitting physician reasonably expected that the necessary hospital care (including earlier 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 forthe acute inpatient hospital care provided from January 21, 2020 to January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic aorta catheter placement (36221 and 36228) and angiographies (75716 and 75898).You asked the Plan to pre-approve thoracic aorta catheter placement and angiographies. You say that endovascular treatment is recommended due to potential lifetime rupture risk.The Plan denied your request. The Plan says the risk of intraoperative complications is higher that the risk of rupture of the aneurysm.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 thoracic aorta catheter placement and angiographies. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the aneurysm appears to have been stable over time, and there are no risk factors for rupture identified in this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thoracic aorta catheter placement and angiographies have not been met.Therefore, we decided that the Plan does not have to pre-approve thoracic aorta catheter placement (36221 and 36228) and angiographies (75716 and 75898).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CPT code 71045 provided on November 16, 2019.
You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the case file does not contain evidence that CPT code 71045 cannot
be paid as it was billed, according to Medicare rules. The file does not contain a copy of a claim that contains
the CPT code 32555 that the health plan states CPT code 71045 is bundled with. It cannot be verified that
payment for CPT code 71045 is bundled with another procedure that was billed on the same date of service.
Therefore, we decided that the Plan has to pay for CPT code 71045 provided on November 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system, expandable controller, multi-function switches, and power wheelchair expandable controller upgrade.
You asked the Plan to pre-approve these power wheelchair accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered. Medicare rules say that expandable controllers are only covered for certain indications. Review of the file shows that while there are three approved power options on this wheelchair, there is not a medical need to control these power options through the joystick. The documentation shows that the enrollee has strength and function in the right and left upper limbs where it would be adequate for the enrollee to be able to control the power options using their own switches included in the allowance of the power options. Additionally, the approved power options come with their own switches so the expandable controller upgrade is not needed.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system, expandable controller, multi-function switches, and power wheelchair expandable controller upgrade.