Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have two heal spurs that are painful. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you didn't have time to seek pre-authorization. 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 eye exam provided on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the neurostimulator analysis testing you had on March 16, 2021.
You asked the Plan to waive the copayment for the neurostimulator analysis testing. You say that you already paid your specialist copayment for this date and do not believe you received any other services for which another copayment should apply. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this testing ($23.32) is less than your copayment obligation, you are responsible for the full allowed amount for this service.
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 $50 copayment for outpatient diagnostic tests. You have been asked to pay a $50 copayment for the neurostimulator analysis testing. Your contract explicitly states that you pay a separate copayment for testing you receive at a physician's office. That is why the neurostimulator analysis testing falls within the outpatient diagnostic tests 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 neurostimulator analysis testing you had on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you had this referral three years ago. You say that you do not know why you were denied this time. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 26, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says per Medicare guidelines, the ambulance benefit is a transport benefit. If there is no transport, then there is no Medicare-covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on March 26, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on January 26, 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 codes 95955, 95885, 95937, 95908, and 95927 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 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head.

We find that CPT codes 95955, 95885, 95937, 95908, and 95927 are not supported in the medical record. Specifically, there is no documentation of an EEG during nonintracranial surgery to support code 95955. There is no documentation of needle electromyography to support code 95885. There is no documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of short-latency somatosensory evoked potential study to support code 95927.

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 testing services rendered on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on June 4, 2020 by a non-participating provider.
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 rendered by a non-participating 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 referring provider 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 drug testing provided on June 4, 2020 by a non-participating provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (36215, 75710) provided March 2, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed CPT codes are not eligible for separate payment.
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 codes 36215, & 75710 are not supported in the medical record. Specifically, the billed CPT codes are inclusive to CPT 36902, which was already approved for payment by the plan. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (36215, 75710) provided March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve the portable ventilator. You say that the portable ventilator is necessary. The Plan denied your request. The Plan says the documentation is insufficient to support medical necessity.
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 portable ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation to suggest a BiPAP was utilized due in part to concerns that the BiPAP device cannot provide needed inspiratory pressures. The patient has chronic respiratory failure consequent to chronic obstructive pulmonary disease. The documentation in the medical record does not support that the ventilator at issue is medically necessary and reasonable for this patient.
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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the power wheelchair. You say that you require the device. The Plan denied your request. The Plan says there is no documentation of postural instability or upper extremity weakness causing inability to operate motorized scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. Also the enrollee's home must provide adequate access between rooms, maneuvering space, and surfaces for the operation of the PMD that is provided. The file does not show that you do not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day. There is also insufficient evidence that the beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for safe operation of the PMD. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the driving aid for your prosthetic (E1399).
You asked the Plan to pre-approve the driving aid for your prosthetic. You say that this item is necessary. The Plan denied your request. The Plan says this item is not covered because it is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. It is considered to be a convenience item. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the driving aid for your prosthetic (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on March 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code.
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 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (70450) provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81301, 81201, 81318, 81321) provided
on March 31, 2021.

You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your
request. The Plan says this was not billed correctly.

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 codes 81301, 81201, 81318, and 81321 is not supported in the medical record. Specifically,
these codes were used to report Guardant360 testing, which should be billed with 81479.

Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been
met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81301, 81201, 81318,
81321) provided on March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on October 7, 2020.
You asked the Plan to waive the copayment for an EGD. You say that you did not receive the procedure and the Plan should not process the claim. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received an EGD at an outpatient hospital facility on October 7, 2020. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment.
You have been asked to pay a $250 copayment for an EGD. An EGD falls 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 an EGD provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control (E2331) for a power mobility
device.
You asked the Plan to pre-approve the attendant control. You say that the claim should be paid. The Plan
denied your request. The Plan says the power mobility device is overturned, but the attendant control is not
covered.
The Plan follows Medicare rules. Medicare rules say that an attendant control cannot be covered in addition to
a beneficiary-operated joystick.
The file shows that there is already a beneficiary operated joystick, so the attendant control (E2331) is not
covered. Therefore, we decided that the Plan does not have to pre-approve an attendant control (E2331) for a
power mobility device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 30, 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 procedure is inpatient-only.

The Plan must follow Medicare rules. The rules say that inpatient-only procedures are not payable in the outpatient setting. 

We looked at the file and Medicare rules. Billed procedure code 32673 (thoracoscopy, surgical; with resection of thymus, unilateral or bilateral) is an inpatient-only procedure that was billed on an outpatient claim. The services are not payable as outpatient. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on November 27, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on November 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S0215) provided to the enrollee on September 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S0215 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 (S0215) provided to the enrollee on September 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 31, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on August 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home sleep test (G0399).
You asked the Plan to pre-approve a home sleep test. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has already been diagnosed.
The Plan follows Medicare rules. Medicare rules say that he physician services related to home sleep testing (G0398, G0399 and G0400) are covered for the purpose of testing a patient for the diagnosis of obstructive sleep apnea if the home sleep testing is reasonable and necessary for the diagnosis of the patient's condition. 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 a home sleep test. Our reviewer says that the requested home sleep study is not medically necessary. Our physician reviewer found the patient does not require a home sleep study as she has already been diagnosed with sleep apnea. She instead requires a supervised study to fit the right device and pressures. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home sleep test have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep test (G0399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received from March 9, 2020, to March 30, 2020.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you are on a fixed income. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for chemotherapy drugs. You have been asked to pay 20% coinsurance for the chemotherapy drugs. 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 chemotherapy drugs you received from March 9, 2020, to March 30, 2020.