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

 We decided that the Plan does not have to waive the cost share for the intravenous infusion and Part B drug provided by an in-network facility on August 25, 2021.   You asked the Plan to waive the cost share for the intravenous infusion and Part B drug. You say that you were told the plan would cover the services with a nominal copayment. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 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 and 20% coinsurance for each in-network Medicare-covered Part B drug.   You have been asked to pay a $246.76 copayment for the intravenous infusion which is less than the standard copayment amount. You have been asked to pay $669.79 which is 20% of the allowed amount for the Part B drug. The intravenous infusion falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Part B drug falls within the "Medicare Part B Prescription Drugs" benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the intravenous infusion and Part B drug provided by an in-network facility on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on
September 14, 2021.
You asked the Plan to waive the copayment for the outpatient hospital services. You say that the services
should be covered as you were misinformed about your copayment The Plan denied your request. The Plan
says the cost-sharing applies 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 $350
copayment for Outpatient hospital observation.
You have been asked to pay a $350 copayment for outpatient hospital services. Outpatient hospital services fall
within the Outpatient hospital observation 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 outpatient hospital services provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 30, 2021.
You asked the Plan to pay for the Guardant360 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 in the Medicare rules section, are not covered. Review of the file shows that the enrollee has lung cancer. The documentation does not show that the testing requested was performed for or that the enrollee was seeking further treatment. This means that the Guardant360 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 Guardant360 testing provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on  July 28, 2021.  You asked the Plan to pay for chiropractic manipulative treatment. The Plan denied your request. The Plan says prior authorization was not obtained by the provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment provided on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopic hernia repair (43281) provided on May 19,
2021.
You asked the Plan to pay for the laparoscopic hernia repair (43281). The Plan denied your request. The Plan
says procedure code 43281-59 is not supported by the medical records submitted.
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 43281 is laparoscopy, surgical, repair of paraesophageal
hernia, includes fundoplasty, when performed; without implantation of mesh.
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 the laparoscopic hernia repair (43281). Our reviewer says
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer
found that the operative report does not describe laparoscopic ports in the upper abdomen, through which the
appropriate surgical instruments are inserted.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the laparoscopic hernia repair (43281) have not been met. Therefore, we
decided that the Plan does not have to pay for the laparoscopic hernia repair (43281) provided on May 19,
2021.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 patient is living at home with progressive problems with gait and balance despite
outpatient physical therapy. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home oxygen equipment provided by an
in-network provider on September 10, 2021.
You asked the Plan to waive the coinsurance for the home oxygen equipment. You say that you cannot afford
this bill. The Plan denied your request. The Plan says you have been asked to pay 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 20%
coinsurance for Medicare-covered items with a total rental or purchase price of $350.01 or more of the
Medicare allowable rate per item.
You have been asked to pay $331.37 which is 20% of the allowed amount for the home oxygen equipment. The
allowed amount is $1,656.84. ($1,656.84 x 20% = $331.37). The home oxygen equipment falls within the
"Durable medical equipment (DME) and related 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 coinsurance for home oxygen equipment provided by an in-network provider on September 10,
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuation of outpatient mental health services with an out of network (OON) provider.  You asked the Plan to pre-approve the continuation of care with an OON provider. You say that switching providers again would be disruptive to the enrollee's psychiatric care. You say that a continuation of care with the OON provider is necessary to ensure proper clinical care and stability. The Plan denied your request. The Plan says there are contracted providers who can supply the care needed.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care.   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 continuation of care with an OON provider. Our reviewer says that the criteria for OON care have not been met. Our physician reviewer found there is nothing unique about the enrollee's condition that would make it medically necessary for her to continue care with the OON provider. The Plan has shown that they have network psychotherapists who have the qualifications and expertise necessary to meet the current Standards of Care required to treat the enrollee's condition. The enrollee's medical management and/or follow-up care can be safely transitioned to a network specialist at this time.  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 continuation of care with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of outpatient mental health services with an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits, and specialist services provided from July 16, 2021, to August 20, 2021.
You asked the Plan to waive the copayments for the specialist office visits and specialist services. You say that you paid for the first copayment on July 14, 2021. After the services provided on that date your hearing got worse and you were forced to see the same doctor multiple times for the same reason. The Plan denied your request. The Plan says the proper copayments were applied for the services, and they are addressing the quality-of-care with this provider.
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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You were charged a $45 copayment for each office visit on July 16, 2021, and July 26, 221. The total copayment for the office visits was $90 ($45 copayment + $45 copayment). The total amount billed for the specialist services on August 20, 2021, was $41.98 which is less than the copayment of $45. Therefore, only a $41.98 copayment was charged. In total the copayment amount for these services is $131.98 ($90 copayment office visits + $41.98 copayment for specialist services). You have been asked to pay a $131.98 copayment for the specialist office visits and the specialist services. A specialist office visit and specialist services 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 copayments for the specialist office visits, and specialist services provided from July 16, 2021, to August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services received on September 5, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by coding regulations.
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 imaging services received on September 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the requested ventilator. The Plan denied your request. The Plan says a ventilator set in a mode that could be delivered by a BiPAP device is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 requested ventilator. Our physician reviewer found that this enrollee has had repeated hospitalizations for hypercarbic respiratory failure, successfully treated with BiPAP and AVAPS support in the hospital. The etiology of the respiratory failure is unclear from the information available. There is a history of progressively worsening muscle weakness, falls, and reduced mobility. One inpatient note indicates a request for a neurology evaluation, but the results of that evaluation are not provided.
Pulmonology notes indicate worsening hypercarbia in the morning when on BiPAP, but that data is not provided. There is mention of bedside spirometry, but those results are not provided. Lung examinations are normal in the hospital, and chest imaging suggests reduced inflation rather than hyperinflation, so it seems likely the primary etiology of the respiratory failure is neuromuscular disease, rather than obstructive lung disease. Medicare does not cover a home ventilator when used as BiPAP. Therefore, a home ventilator is not medically necessary at this time. 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 requested ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on September 2, 2021.
You asked the Plan to pay for the consultation. You say that you feel you should not have to pay for this service because you were told this provider was in-network. The Plan denied your request. The Plan says this dental service is not covered by your medical plan.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on September 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Neuromuscular junction testing (95937) provided on April 22, 2021.  You asked the Plan to pay for code 95937. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, the CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.  We find that CPT code 95937 is not supported in the medical record. Specifically, the record shows that train of four testing was performed, and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Therefore, we decided that the Plan does not have to pay for the Neuromuscular junction testing (95937) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedure codes 51785, 95861, 95870)
provided to the enrollee on June 1, 2021.
You asked the Plan to pay for the services. You say that the medical records support the billing of code 51785
and the use of modifier -59 with codes 95861 and 95870 provided on June 1, 2021. The Plan denied your
request. The Plan says the medical records do not support the billing of code 51785 and the use of modifier -59
with codes 95861 and 95870 provided on June 1, 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 the denied codes is:
CPT 51785:
Needle electromyography studies (EMG) of anal or urethral sphincter, any technique
CPT 95861:
Needle electromyography; 2 extremities with or without related paraspinal areas
CPT 95870:
Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters
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 the services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found CPT 95861 and 95870 would be
included in CPT 95929, as they would be performed as part of the procedure. In terms of CPT 51785, the
technical report does not describe placement of pad or needle in the anal or urethral sphincter, with
measurement of electrial activity with the bladder filling and emptying.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (procedure codes 51785, 95861, 95870) provided to the enrollee on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy (S9502) provided from July 7, 2021, through July 14, 2021.  You asked the Plan to pay for the home infusion therapy (S9502). The Plan denied your request. The Plan says CPT code S9502 is not valid for Medicare purposes.  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 S9502 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.    We find that CPT code S9502 is not supported in the medical record. Specifically, CPT code S9502 has a status indicator of I. This means that CPT code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy (S9502) have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9502) provided from July 7, 2021, through July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided on September 14, 2021.

You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that you would like to appeal this service. The Plan denied your request. The Plan says this procedure is not a benefit under the dental plan.

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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided on September 14, 2021.