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

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on May 18, 2021. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you usually pay a $35 copayment 
and disagree with the higher charges. 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. 
 
You received arthrocentesis at an outpatient hospital facility on May 18, 2021. Arthrocentesis 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 arthrocentesis. Arthrocentesis 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 arthrocentesis provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx? (CPT code 81551) provided to the enrollee on May 3, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says screening services without a valid medical diagnosis related to the health of the patient are not a benefit. The Plan says the prior biopsy was negative for cancer, there was no documented result of prior prostate biopsy, and there was no documented significant interval increase in prostate-specific antigen (PSA) level.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the service. Our physician reviewer found a prior biopsy was negative for cancer. There was no documented result of prior prostate biopsy. There was no documented significant interval increase in PSA level. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 service have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx? (CPT code 81551) provided to the enrollee on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve a CPAP device. You say that you were not compliant in using the CPAP
machine because you were not taught or coached in how to use it. You say that the device was dropped off at
your doorstep. You say that the mask did not fit properly and the one that did fit took your breath away. You
say that you lacked knowledge of the settings on the machine. The Plan denied your request. The Plan says the
requested device is not medically necessary as the compliance report demonstrates 54% compliance with a
daily use of 2 hours and 59 minutes.
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device will be denied as
not reasonable and necessary when there is not objective evidence of adherence to use the PAP device.
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 CPAP device. Our reviewer says that
the criteria for coverage have not been met. Our physician reviewer found the compliance report demonstrated
54% compliance with a daily use of 2 hours and 59 minutes. Our physician reviewer found that the records do
not show that the enrollee is eligible to requalify for the PAP device, as there is no evidence of an in-person
clinical re-evaluation by the treating practitioner to determine the etiology of the failure, nor has there been a
repeat sleep test in a facility-based setting.
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 CPAP device have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bronchiectasis, 
multiple pulmonary nodules of uncertain significance, and recurrent infections with cough. She does not 
tolerate the vest system for airway clearance because of chest pain. The record does not indicate that she has 
tried a flutter valve. Pulmonary physiotherapy is administered once weekly by a visiting nurse, but this is 
insufficient to provide benefit. The Volara system includes positive expiratory pressure for lung expansion, 
intra-airway oscillation, and nebulizer therapy. There is insufficient evidence to support the efficacy of this 
device in the treatment of lung disease in the home setting. The nebulizer component duplicates that aspect of 
her current therapy. The services are therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Volara System.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound (76705) provided 
on May 3, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $75 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).   
 
You have been asked to pay $60.13 for the Medicare-covered radiological diagnostic service provided. This is 
the Plan's allowed amount for this service, which is less than the applicable copayment. 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 abdominal ultrasound (76705) provided on 
May 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. There are no services at the LTACH that the enrollee requires that are not already available or covered at the current facility. 

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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on
April 21, 2021. ked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this is not separately payable.
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 a computed tomography (CT) scan (70450) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on May 26, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on June 15, 2021.
You asked the Plan to pay for subsequent hospital care (99231). You say that the Plan should pay this claim. The Plan denied your request. The Plan says payment may not be made for services included in the anesthesia care package when furnished by the same provider or the same provider specialty within a group practice.
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 subsequent hospital care 99231 has a bundled relationship with code 01402 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 subsequent hospital care provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair with additional accessories 
(E2313, E2377, K0108, E2300). 
 
You asked the Plan to pre-approve the new items. You say that this is medically necessary. The Plan denied 
your request. The Plan says the current power wheelchair is meeting mobility needs. 
 
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 new items. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the enrollee needs this 
new wheelchair over the current one. The records indicate that the current wheelchair was provided in January 
2019. It is in good working condition, and it has power tilt and recline. The power standing feature is not 
covered. 
 
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 new items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new power wheelchair with additional accessories (E2313, E2377, K0108, E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove intermittent limb compression device.
You asked the Plan to preapprove intermittent limb compression device. You say that the services should be covered. The Plan denied your request. The Plan says the documentation did not show that you have tried and failed four weeks of conservative therapy.
The Plan follows Medicare rules. The rules state that for pneumatic devices (E0651 or E0650) to be covered, a four-week trial of conservative therapy demonstrating failed response to treatment is required. The file does not show that the enrollee has had failed treatment of conservative therapy including elevation, pressure garments, or exercise. Therefore, we decided that the Plan does not have to preapprove intermittent limb compression device.
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 the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 pre-approve a sock donner (E1399).
You asked the Plan to pre-approve a sock donner. You say that you were in a car accident in 1985 that left you with difficulty walking and weakness in the hands. You have chronic pain in your neck and lower back. The Plan denied your request. The Plan says a sock donner is does not primarily serve a medical purpose and is not covered
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 a sock donner (E1399).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95955), needle
electromyography (95885), neuromuscular junction testing (95937) and nerve conduction studies (95908)
provided on November 12, 2020.

You asked the Plan to pay for the EEG, needle electromyography, neuromuscular junction testing and nerve
conduction studies. You say that you would like reconsideration based on the records submitted. 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.

In this case, the CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during
nonintracranial surgery (eg, carotid surgery).

The CPT Code Manual 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 CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 

The CPT Code Manual definition of code 95908 is Nerve conduction studies; 3-4 studies. 

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 EEG, needle electromyography, neuromuscular junction testing and nerve conduction studies. Our reviewer says that CPT codes 95955, 95885, 95937 and 95908 do not meet criteria for billing or reimbursement consideration. Our reviewer found for CPT 95955, the technical report documents "real-time" monitoring, with no additional testing. This is the incorrect code to report for this service. As of note, any additional testing would be included in the primary code when coded correctly. For CPT 95885, the technical report does not document nerve conduction studies as required to report this code. Therefore, this procedure would not be covered. For CPT 95937, the technical report does not document Neuromuscular junction testing. Documentation does support Train of four testing, which is included in the primary code, and not billed separately. For CPT 95908, the technical report does not include documentation of amplitude, latency and conduction velocity performed with electrodes. Report documents "pedicle screw stimulation," CPT 95908 is the incorrect code to report for this procedure. 

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 EEG, needle electromyography, neuromuscular junction testing and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95955), needle electromyography (95885), neuromuscular junction testing (95937) and nerve conduction studies (95908) provided on November 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network occupational therapy services. 
 
You asked the Plan to pre-approve out-of-network occupational therapy services. You say that he needs 
occupational therapy services and you have attached the orders from the doctor. The Plan denied your request. 
The Plan says services are available with Plan providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan.

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve out-of-network occupational therapy services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy.
You asked the Plan to pre-approve out-of-network physical therapy. You say that it is dangerous to drive through the hills and you don't want to go to a physical therapist an hour away. The Plan denied your request. The Plan says in-network providers are available including physical therapy at home.
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 out-of-network physical therapy.