Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the Angiography (75710) provided on February 23, 2021.
You asked the Plan to pay for code 75710. You say that the medical records support the billing of code 75710 provided on February 23, 2021. The Plan denied your request. The Plan says that the medical records do not support the billing of code 75710 provided on February 23, 2021.
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 75710 is Angiography, extremity, unilateral, radiological supervision and interpretation. 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 code 75710. Our reviewer says that the medical records support the billing of code 75710 provided on February 23, 2021. Our reviewer found the procedure in question was done through a fistula created for dialysis. Thus, the standard Selinger technique was not necessary for access. In other words, no percutaneous puncture was necessary. Nonetheless, there is appropriate documentation of the arterial injection through a catheter after using a guidewire for placement. Hence, 75710 did occur, is documented, and should be reimbursed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 75710 have been met. Therefore, we decided that the Plan has to pay for the Angiography (75710) provided on February 23, 2021.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 5, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you should not have to pay this copayment because you went into anaphylactic shock from the dye used for a computed tomography (CT) scan. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits. 

You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER 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 the emergency room (ER) visit you had on July 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided February 11, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the medical records (11, office setting). 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 for lab services (G0483) provided February 11, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve twice weekly home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that if the doctor determines that more home visits are needed, a request can be submitted that includes progress and information supporting medical need.
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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found twice weekly services requested. Less than once weekly or, the first 3.5 weeks were approved. It is the 12/6 evaluation that should have been used to determine whether the requested services were medically necessary and reasonable. The health plan is using the progress shown on 12/28 to effectively deny ongoing services, without issuing a decision as to whether the services were medically necessary and reasonable when requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve twice weekly home health services for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower grab bar.

You asked the Plan to pre-approve a shower grab bar. You say that it has become very difficult to enter your bathtub and are afraid of falling. The Plan denied your request. The Plan says that grab bars are not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower grab bar.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten (10) additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for destruction of benign lesions (17110) provided on July 21, 2021.

You asked the Plan to waive the copayment for the destruction of benign lesions. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $325 copayment for Outpatient surgery and Other Medical Services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.

You have been asked to pay a $154 copayment for destruction of benign lesions, which is less than the $325 stated in the Plan's contract. Destruction of benign lesions fall within the Outpatient surgery and Other Medical Services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers Plan 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 destruction of benign lesions (17110) provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services (17311, 15004, 69310) provided on June 29, 2021, to July 26, 2021
You asked the Plan to waive the copayment for the surgical services. You say that the services should be covered as you already paid $150 for a previous unrelated claim. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $125 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $125 copayment for three surgical visits provided on June 29th, 2021, June 30th, 2021, and July 26th, 2021 ($125x3=$375). The record indicates that these services were performed in an outpatient setting. The surgical services 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 waive the copayment for surgical services (17311, 15004, 69310) provided on June 29, 2021, to July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the SNF services you and/or your provider are requesting do not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee appears to be at/near her baseline, and her care needs can be provided at a lower level of care (ex. long term care). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided May 21, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed.
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, we have confirmed that code 70450 is a column II code to column I code 70496.
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450) provided May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac contractility modulation (CCM) system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue in this case is whether implantation of the requested CCM system is medically necessary in an enrollee for treatment of congestive heart failure which has been deemed refractory to optimal medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM.
Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac contractility modulation (CCM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a polycarbonate lens (V2784) provided on August 23, 2021.

You asked the Plan to pay for a polycarbonate lens. You say that you have one functioning eye, and you need polycarbonate lenses to protect your eye according to your doctor. The Plan denied your request. The Plan says polycarbonate lenses are not a benefit of your vision plan.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyeglass frames and eyeglass lenses including single, lined bifocal, lined trifocal, and lenticular lenses. 

We looked at the file and the Plan's rules. The EOC confirms that the Plan covers standard lenses such as single, lined bifocal, lined trifocal and lenticular lenses. The EOC also confirms that enhancements are not included in your Plan. Based on this information, we decided that the Plan's rules for coverage of a polycarbonate lens have not been met. Therefore, we decided that the Plan does not have to pay for a polycarbonate lens (V2784) provided on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021, billed with code 81295.
You asked the Plan to pay for the billed code 81295. You say that this is medically necessary. The Plan denied your request. The Plan says this code is not payable when billed on the same date as 81432.
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, we have confirmed that the billed code 81295 is a column II code to column I code 81432. This is not payable even if a modifier is used.
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021, billed with code 81295.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health care visits provided from July 6, 2021 to September 1, 2021.

You asked the Plan to waive the copayments for the outpatient mental health care visits. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient mental health care visits on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient mental health care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient mental health care visits from July 6, 2021 to September 1, 2021. You have been asked to pay a $40 copayment for each outpatient mental health care visit. The outpatient mental health care visits fall within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the outpatient mental health care visits provided from July 6, 2021 to September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (LTACH).
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee was admitted for sepsis acute respiratory failure due to pneumonia. The record indicates that the enrollee has had a prolonged hospital course with acute kidney injury
requiring dialysis and encephalopathy from viral meningitis. The record indicates that the enrollee still requires acute care services that are being provided and have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request to pre-approve laboratory services out-of-area does not meet criteria for coverage.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the laboratory services requested out-of- area in this case are not unforeseen. Although, it may be necessary for you to receive routine laboratory services while you are away, your request does not meet criteria for coverage under your contractual policy.
The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and preapproved care. Therefore, we decided that the Plan does not have to pre-approve laboratory services to be rendered by the out-of-network (OON) provider