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

We decided that the Plan does not have to waive the copayment for specialist office services provided on August 19, 2020, by an in-network provider.
You asked the Plan to waive the copayment for the services. You say that the services were a post-operative visit and you had never been charged in the past. The Plan denied your request. The Plan says you did not receive the services within the global surgical period.
The health plan follows Medicare rules. The rules say that The Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. However, the surgery you received was insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling (CPT Code 64590) and according the MFSDB this CPT Code has a 10 day global period. According to the records you had the surgery services (64590) on July 29, 2020. The global period is 10 days immediately following the day of the surgery. You received your first post-op appointment twenty-two (22) days after your surgery date.
Therefore, you are asked to pay a $40 copayment for the specialist office visit. 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 specialist office services provided on August 19, 2020, by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvereceiver (monitor); external, for use with interstitial CGMsystem (CPT Code A9278), sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial 
continuous glucose monitoring system, one unit = 1 day supply (A9276) and transmitter; external, for use with interstitial continuous glucose monitoring system (A9277).You asked the Plan to pre-approvethe DME. You say that the DME is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.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 DME have not been met. Medical necessity has not established, since the patient is not on insulin and no documentation in the frequency of glucose testing.Therefore, we decided that the Plan does not have to pre-approvereceiver (monitor); external, for use with interstitial CGM system (CPT Code A9278), sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply (A9276) and transmitter; external, for use with interstitial continuous glucose monitoring system (A9277).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the moderate sedation services rendered on October 23, 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 that procedure code 99153 has a PC/TC indicator of 3 and cannot be billed with the -26 modifier.
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. The Plan states that billed procedure code 99153 cannot be paid when billed with the -26 modifier for the PC of the services; however, the claim shows that the provider did not bill the -26 modifier with this code. Therefore, we decided that the Plan has to pay for the moderate sedation services rendered on October 23, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on December 2, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. 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 forthe testing services rendered on December 2, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe arthrocentesis and injection services rendered on February 28, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 62323 and 20610 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 62323 is injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT). The definition of code 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance.We find that CPT codes 62323 and 20610 are not supported in the medical record. Specifically, there is no documentation of the actual date of service to support either 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 forthe arthrocentesis and injection services rendered on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker.
You asked the Plan to pre-approve the walker. You say that this should not be denied due to your MS condition. The Plan denied your request. The Plan says the most appropriate item would be a scooter.
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 walker. Our reviewer says that the requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer found you were authorized to have a physiatry evaluation, and it does not appear that you have had this yet. You were noted to be a fall risk in the past with a walker. The documentation does not clearly support that the upright walker would be safe and effective for you. 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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvediagnostic facet joint injections for the enrollee.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysthere has not been at least three months of moderate pain despite conservative care for the most recent back injury.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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there have not been at least three months of moderate to severe pain that has not responded to conservative care. The pain is not associated with radiculopathy or neurogenic claudication.  However, there is no documentation provided indicating that the facet joint is the main source of pain. The requested injections are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approvediagnostic facet joint injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
from July 1, 2020, to July 6, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you were not in the SNF for 10 days, so
you should not be charged for this. The Plan denied your request. The Plan says the copayment amount you are
being charged is correct.
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 $20
copayment per day for days 1 to 20, $60 copayment per day for days 21 to 44, and $0 copayment per day for
days 45 to 100 for Skilled Nursing Facility (SNF) Care. This SNF stay lasted 5 days, resulting in a total
copayment amount of $100.
You have been asked to pay $20 copayment per day for days 1 to 20, $60 copayment per day for days 21 to 44,
and $0 copayment per day for days 45 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility
(SNF) Care 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 skilled nursing facility
(SNF) care provided from July 1, 2020, to July 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveKeytruda, Pemetrexed, Carboplatin, Dexamethasone, Emend, and Aloxi for the enrollee.You asked the Planto pre-approvethe drugs. You say that the enrollee is an appropriate candidate for treatment.The Plandenied your request. The Plansaysthe use of these drugs requires the regimen to be used as first-line therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drugs. Our reviewer says that the requested drug regimen is not medically reasonable and necessary. Our physician reviewer found the enrollee has progression on keytruda. Adding chemotherapy to this regimen would not be indicated after progression. Multiagent chemotherapy is also not indicated after progression. The service is not reasonable or medically necessaryWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drugs have not been met.Therefore, we decided that the Plandoes not haveto pre-approveKeytruda, Pemetrexed, Carboplatin, Dexamethasone, Emend, and Aloxi for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit provided on June 24, 2020 by an out of networkprovider.You asked the Plan to pay forthe home visit. You say that the facility did not obtain authorization.The Plan denied your request. The Plan says you did not request authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe home visit provided on June 24, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip and coinsurance for durable medical equipmentprovided by participating providers on July 9, 2020, to July 17, 2020.You asked the Plan to waive the copayment and coinsurance for an ambulance trip and durable medical equipment. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct charges have been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for ambulance services/ground ambulance and a 20% coinsurance for durable medical equipment. You have been asked to pay $281.18 which is less than your copayment amount of $300 for an ambulance trip. You have been asked to also pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $375.56. The amount you are being asked to pay for durable medical equipment is $75.11 ($375.56 x 20% = $75.11). The total amount you are being asked to pay is $356.29 ($75.11 + $281.18 = $356.29). Anambulance trip falls within the ambulance services/ground ambulance benefit category and durable medical equipment falls within the durable medical equipment 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 ambulance trip and coinsurance for durable medical equipmentprovided by a participating provider on July 9, 2020, to July 17, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay foremergency department visit for the evaluation and management of a patient (99284) provided June 2, 2020.You asked the Plan to pay forthe emergency visit. You say that CPT code 99284 was denied as missing/incomplete/invalid diagnosis or condition. The diagnosis billed are substantiated in the attached supporting documentation. Please review for payment.The Plan denied your request. The Plan says that claim/service lacks information or has submission/billing errors. Missing/incomplete/invalid diagnosis or condition.The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided.  In this case, you billed CPT code 99284. The definition of CPT code 99284 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):1. a detailed history;2. a detailed examination; and3. medical decision making of moderate complexity.In addition, CPT code 99284 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 emergency visit Our reviewer says that the requested items/services is supported in the medical records provided in this case. Our physician reviewer found the enrollee wasevaluated in the ED for GI symptoms the day after receiving chemotherapy. The enrollee received a comprehensive review of systems and physical examination. Laboratory studies were checked and IV hydration was provided. Infectious causes were excluded and the enrollee improved.  He was discharged with a lay diagnosis of "medication reaction." This translates well to the billed codes of K52.1 and T45.1.  The documentation supports the services billed.
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 emergency visit have been met.Therefore, we decided that the Plan has to pay foremergency department visit for the evaluation and management of a patient (99284) provided June 2, 2020
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from December 14, 2019, to December 16, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the medical record evidences that an inpatient admission was medically reasonable and necessary. You urge the plan to render a fully favorable decision and retract the denial.The Plan denied your request. The Plan says that a decision was not made in the allotted timeframe of 60 calendar days.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 enrollee with combination of several acute problems and underlying chronic illnesses met admission criteria. The enrollee had a fever up to 102, tachycardia, altered mental status, evidence of acute hepatic injury and hypoxemia among other problems with acute presentation.It was medically reasonable at presentation that this enrollee would require 2 or more 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 December 14, 2019, to December 16, 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/orsend 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided.

You asked the Plan to pay for inpatient hospital care. You say that you did not receive notification of the enrollee's health insurance coverage timely.The Plan denied your request. The Plan says this claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January, must be filed no later than one calendar year after the date of service.

The record shows that a claim for inpatient hospital care was not filed until. 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 inpatient hospital care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) received on May 17 to May 21, 2019.
You asked the Plan to pay for hospital care. You say that this claim was originally paid by Medicare and that you had no reason to believe another carrier was primary at the time of service. The Plan denied your request. The Plan says rules for payment have not been met.
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 hospital care was not filed until July 24, 2020. 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 hospital care (99233) received on May 17 to May 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of interbody biomechanical device(s) services coded 22853 provided on May 13, 2020.
You asked the Plan to pay for the insertion of interbody biomechanical device(s) services. 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 22853 is insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure).
We find that CPT code 22853 is not supported in the medical record. Specifically, the documentation does not support that insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace was performed. Based on this information, we decided that Medicare rules for coverage of the insertion of interbody biomechanical device(s) services have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of interbody biomechanical device(s) services coded 22853 provided on May 13, 2020.