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

We decided that the Plan does not have to waive the copay for the provision of testing materials provided on July 26, 2021.
You asked the Plan to waive the copay for the testing services. You say that this code is for durable medical supplies. The Plan denied your request. The Plan says the claim processed 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 $45 copay for physician services. You have been asked to pay a $45 copay for the services at issue. The services fall within the physician 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 copay for the provision of testing materials provided on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70544 billed for date of service September 8, 2021.
You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 70551.
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 procedure code 70544 is a column II code to column I code 70551. 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 procedure code 70544 billed for date of service September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided from April
12, 2021 to April 16, 2021.
You asked the Plan to pay for the critical care 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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed dates of service. The documentation does not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided from April 12, 2021 to April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on June 1, 2021.
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 procedure code 01924 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 01924 is anesthesia for therapeutic interventional radiological procedures involving the arterial system; not otherwise specified. We find that CPT code 01924 is not supported in the medical record. Specifically, the records do not show that a therapeutic interventional radiological procedure was performed for which anesthesia was administered. 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 anesthesia services rendered on June 1, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 29, 2021.
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 billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 71045 billed for date of service July 30,
2021.
You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date
of service. The Plan denied your request. The Plan says payment for 71045 is bundled into 71046.
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 procedure
code 71045 is a column II code to column I code 71046. 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 procedure code 71045 billed for date of service
July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ECG provided on July 15, 2021.
You asked the Plan to waive the copayment for the ECG. You say that you have never been charged for the ECG before and that it has always been covered. 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 a $10 copayment per day for Medicare-covered outpatient diagnostic tests.
You have been asked to pay a $10 copayment for the ECG. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the ECG is considered a separate service.
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 ECG provided on July 15, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0429) provided on July 15, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel this cost is too high for the services provided, and you are upset that the emergency room copayment is less than the ambulance cost. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Covered ambulance services require a $325 copayment.
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 ambulance services.
You have been asked to pay a $325 copayment for the ambulance transportation. 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 ambulance transportation services (A0429) provided on July 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided August 23, 2021.
You asked the Plan to waive the copayment for the colonoscopy and biopsy. You say that you needed a routine colonoscopy and don't feel you should have to pay a copayment. The Plan denied your request. The Plan says the colonoscopy rendered was diagnostic and the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for same-day outpatient surgery in a freestanding Ambulatory Surgical Center. You have been asked to pay a $275 copayment for the colonoscopy and biopsy.
The colonoscopy and biopsy are considered a diagnostic colonoscopy and falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been proven to be helpful for the enrollee's condition.
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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.
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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on May 7, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. 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 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. Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided during a surgical procedure on June 18, 2021, billed with code 99190.
You asked the Plan to pay for the heart/lung machine services. You say that this is a medically necessary services which should be reimbursed. The Plan denied your request. The Plan says this service is included in payment to the facility.
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The rules also indicate that in order to bill Medicare and receive payment, a provider must be enrolled in the Medicare program.
Although these services may be appropriate, payment for them is made to the hospital which must then furnish
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for
the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly and operation
of a heart/lung machine provided during a surgical procedure on June 18, 2021, billed with code 99190.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on August 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that the services were rendered in good faith. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the debridement provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac risk assessment genetic screening testing provided to the enrollee on November 18, 2020.
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your request. The Plan says the documentation shows that the testing was initiated by the laboratory and not by the treating physician.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the obtained cardiac genetic testing. Medicare covers cholesterol testing with a total cholesterol/HDL/LDL and triglycerides.
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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac risk assessment genetic screening testing provided to the enrollee on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton treatment delivery simple with compensation for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clear evidence that supports a benefit or decrement to proton therapy over intensity-modulated radiation therapy (IMRT) for either treatment efficacy or long-term toxicity.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of proton therapy is an accepted radiation technology, which has proven efficacy and tolerability. Whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a heated issue, with quite disparate opinions among experts in the field. In general, proton therapy is more expensive than photon therapy, which is the root of the disagreement of experts. Whether proton therapy for prostate cancer affords any advantage over IMRT is very controversial. Any potential benefit or detriment of proton
therapy over standard IMRT is an investigational question (being pursued in randomized studies- i.e. for intermediate to low risk prostate cancer. Thus, whether proton therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation and remains controversial. Particularly with the use of the SpaceOAR hydrogel spacer, the risk of gastrointestinal/rectal toxicity is low (since the rectum is pushed away from the prostate) such it is even more unlikely that there would be a potential benefit from proton therapy. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton treatment delivery simple with compensation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) paring or cutting of benign hyperkeratotic lesion (11056) debridement of mycotic nails (11721) provided June 15, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you want to appeal because you have never had to pay for the services before. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $30 copayment for each Medicare covered podiatry visit for Podiatry services. You have been asked to pay $30 copayment for the office visit. The office visit falls within the Podiatry services benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) paring or cutting of benign hyperkeratotic lesion (11056) debridement of mycotic nails (11721) provided June 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency transportation: wheelchair van (A0130) provided July 29, 2021.
You asked the Plan to waive the copayment for the non-emergency transportation services. You say that you would like this service covered. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for Ambulance services. You have been asked to pay $45.90 for the non-emergency transportation services. The non-emergency transportation services fall within the Ambulance services benefit category. This means that you have been
asked to pay less than or equal to 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 non-emergency transportation: wheelchair van (A0130) provided July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a replacement CPAP device (E0601) purchased on July 23, 2021.
You asked the Plan to pay for a CPAP device. You say that you are due for reimbursement because you had nothing to do with your prior machine being defective and recalled. You also say that you needed the CPAP device to sleep and there were no rentals available. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules provide only for rental of CPAP devices and accessories. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device and accessories have not been met. Specifically, you have purchased rather than rented the item at issue. Therefore, we decided that the Plan does not have to pay for a replacement CPAP device (E0601) purchased on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. 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.
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 had network providers available who could have provided 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 for the office visit provided on August 11, 2021 by an out-of-network (OON) provider.