Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

You asked the Plan to pay for allograft and catheter implant. You say that you are appealing with records. The Plan says that the denial of payment for these services is correct, because the record does not support these codes.

We decided that the Plan has to pay for allograft (code 20931).

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 allograft, structural, for spine surgery only (list separately in addition to code for primary procedure).

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 allograft code 20931. Our reviewer says that this code meets criteria for payment. Our reviewer found the operative report documents a structural allograft was performed. Therefore, this service should be covered.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of allograft and catheter implant have been met. Therefore, we decided that the Plan has to pay for allograft.

We also decided that the Plan does not have to pay for catheter implant (62350).

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 implantation, revision, or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implanatable reservoir/infusion pump; without laminectomy.

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for code 62350. Our reviewer says that code 62350 does not meet criteria for payment. Our reviewer found although this code is documented in the operative report, this procedure is considered inclusive to 22633. Therefore, this procedure would not be covered separately.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 62350 have not been met. Therefore, we decided that the Plan does not have to pay for catheter implant.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular surgery services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you were never told about extra paperwork. The Plan denied your request. The Plan says there are an adequate supply of in-network options.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve vascular surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a diagnostic mammography (77065, 77065) and a diagnostic digital breast mammography (G0279) provided on June 18, 2021.

You asked the Plan to waive the deductible for a diagnostic mammography and a diagnostic digital breast mammography. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost share you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for your covered medical services. Your contract with the Plan also says that you pay a $10 copayment after the deductible is met for each basic imaging service.

The service at issue is subject to the Plan deductible of $750. The record shows that at the time this claim was processed, $0 of the $750 deductible had been met. The allowed amount of the claim for each diagnostic digital breast mammography (G0279) is $21.41 and $29.38, resulting in a deductible obligation of $50.79. The allowed amount of the claim for the diagnostic mammography (77065) is $76.84, resulting in a deductible obligation of $76.84. The allowed amount of the claim for the diagnostic mammography (77066) is $48.24, resulting in a deductible obligation of $48.24. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a diagnostic mammography and a diagnostic digital breast mammography was received on June 18, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a diagnostic mammography (77065, 77065) and a diagnostic digital breast mammography (G0279) provided on June 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in an assisted living facility or in a long-term care facility on a part time basis appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography angiography (CTA) services.
You asked the Plan to pre-approve the CTA services. You say that the records provided support the need for the requested CTA services. The Plan denied your request. The Plan says that there is no documentation from a neurologist or neurosurgeon that supports the medical necessity of a repeat CTA.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 CTA services. Our reviewer says that a CTA is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was found to have an ulcerated carotid plaque in the setting of a history of Peripheral Vascular Disease (PVD) and other atherosclerotic disease. She was found to have ulcerated plaque in her Internal Carotid Artery (ICA). Given such a finding, she was started on Dual Anti-Platelet Therapy (DAPT) according to the hospital discharge note. Neurology at the time of discharge recommended repeat imaging 3-4 weeks post discharge on DAPT to evaluate the ulcerated plaque (also found in the discharge note). In such a setting/context, repeat imaging would be medically appropriate and consistent with standards of practice/care for the management of such a finding. The repeat imaging would permit a determination if DAPT has had a positive impact on this finding (from prior imaging). Alternatively, a decision may be made on the need for intervention based on the follow-up findings. In as much such a study would be reasonable and 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 the CTA services have been met. Therefore, we decided that the Plan has to pre-approve computed tomography angiography (CTA) services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cardiac catheterization services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 services. Our physician reviewer found that the enrollee has had prior stenting and has known coronary and peripheral vascular disease. He is having frequent chest discomfort and has at least moderate stenosis of a bicuspid aortic valve, which is worse on his most recent echocardiogram. Although non-invasive testing for ischemia is an option, given his severe known vascular disease and diabetes, he has a high pre-test probability of recurrent obstructive coronary artery disease (CAD). Moving directly to coronary angiography in this patient, as a clinical judgement by the cardiologist, is medically reasonable, backed by published guidelines and meets the indications criteria for left heart catheterization where recurrent ischemia is suspected in a patient with known CAD and prior coronary stenting. In addition, direct catheter assessment of his aortic valvular disease, given the symptoms and signs in a patient with a bicuspid valve, is also medically reasonable and meets CMS guidelines for the use of right heart catheterization in valvular heart disease patients. Right heart catheterization is required to assess the cardiac output when doing a catheter-based calculation of the aortic valve area in order to assess the severity of the stenosis.
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 services have been met. Therefore, we decided that the Plan has to pre-approve cardiac catheterization services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided from April 8, 2021, through April 9, 2021.
You asked the Plan to waive the copayment for the emergency care. You say that the services should be approved, and that you have medical records for review for medical necessity. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received emergency care from April 8, 2021, through April 9, 2021. You were asked to pay a $120 copayment for emergency care. Your 2021 EOC states that enrollees must pay a $120 copayment for emergency care.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency care provided from April 8, 2021, through April 9, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear unable to participate fully in skilled therapy. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective coating provided on June 25, 2021.
You asked the Plan to pay for the anti-reflective coating. You say that you should get $100 toward glasses. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating provided on June 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 23, 2021, forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from October 23, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON laboratory services. You say that the enrollee had no control over which laboratory the doctor sent the test to. The Plan denied your request. The Plan says the enrollee's contract requires that care be obtained from network providers. The Plan says that the laboratory where the services in dispute were provided is not contracted with the Plan. The Plan says that the services were not referred by a network provider, were not urgent or emergent, and were not approved in advance.
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 laboratory services provided on June 1, 2021 by
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied to ambulance services provided on February 15, 2021.
You asked the Plan to waive the copayment applied to the ambulance services. You say that you don't have money to pay this copayment. The Plan denied your request. The Plan says the copayment was appropriately applied to 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 $275 copayment for each one-way trip by ground or air ambulance. You have been asked to pay a $275 copayment for the ambulance services. The ambulance services fall within the Ambulance 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 applied to ambulance services provided on February 15, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments applied to inpatient hospital services provided on January 26 - January 31, 2021.
You asked the Plan to waive the copayments applied to the inpatient hospital services. You say that you had to stay in the hospital longer due to a hospital error. You say that they punctured your artery. You say that you were scheduled to have your artery repaired within the extra 5 day stay but that the provider advised you they had too much going on and that you would have to wait. You say that they put the surgery off and that you were just lying there waiting. The Plan denied your request. The Plan says the copayments were appropriately applied to 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 $395 copayment per day for days 1-5 for Inpatient Hospital Care. You have been asked to pay a $395 copayment per day for days 1-5 for the inpatient hospital services. This totaled $1,975. The inpatient hospital services fall within the Inpatient Hospital Care 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 applied to inpatient hospital services provided on January 26 - January 31, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for angiography (75710) provided on February 18, 2021.
You asked the Plan to pay for angiography. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure is considered inclusive to code 37229 and separate payment is not supported in 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 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for angiography.
Our reviewer says that this code does not meet the Medicare criteria for payment. Our reviewer found you billed this code with modifier -59; however, the procedure report does not support this service as a separate distinct procedure. Modifier -59 should be used to distinguish a different session or patient encounter, different procedure or surgery, different anatomical site, or separate injury. Therefore, this procedure would be inclusive to the primary service reported for this date of service and not covered separately. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of angiography have not been met. Therefore, we decided that the Plan does not have to pay for angiography (75710) provided on February 18, 2021