Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cystoscopy provided on May 4, 2021.  You asked the Plan to waive the copayment for the cystoscopy. You say that the provider was in-network and the procedure was diagnostic in nature. The Plan denied your request. The Plan says you have been charged 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 $345 copayment for outpatient services provided in an ambulatory surgical center.   You have been asked to pay a $345 copayment for the cystoscopy. The cystoscopy falls within the Outpatient Surgery and Other Medical 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 a cystoscopy provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services received on March 1, 2020.  You asked the Plan to waive the copayment for the services. You say that you would like this copayment to be waived, as this should have been billed to you last year. The Plan denied your request. The Plan says the claim was processed appropriately.  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 services. the services falls 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 for ambulance services received on March 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747).  You asked the Plan to pre-approve a non-spinal electrical osteogenesis stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator (E0747) is covered only in the event of nonunion of a long bone fracture, failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery, or congenital pseudarthrosis.  We looked at the file and Medicare rules. The records show that the enrollee does not have a long bone fracture or congenital pseudarthrosis and that it has been fewer than 9 months since her most recent surgery. Based on this information, we decided that Medicare rules for coverage of a non-spinal electrical osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided by an out-of-network provider on August 10, 2021.  You asked the Plan to pay for an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D0431 is not a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) provided by an out-of-network provider on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and an accessory (E0667).  You asked the Plan to pre-approve a pneumatic compression device and an accessory. You say that this is medically necessary. The Plan denied your request. The Plan says the requirement for coverage have not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and an accessory (E0667).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).  You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the member has suffered from this condition for years and has failed 6 months of conservative approaches to treatment. You say that this treatment is considered safe and effective, and the necessary coverage should be provided. The Plan denied your request. The Plan says this procedure is not reasonable or 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 the insertion of stabilization device (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interspinous process distraction devices remain experimental in cases of spinal surgery.     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 stabilization device (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after February 6, 2022.  You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after February 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the foot.  You asked the Plan to pre-approve MRI of the foot. You say that this is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says an MRI would not add additional information that would help treat your medical condition.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the foot. Our reviewer says that the requested MRI services are not medically reasonable and necessary. Our physician reviewer found you are an 85-year-old man with bilateral foot pain. In this case, the review has determined that an MRI would not add additional information that is required to treat your foot condition. There is no recommendation for a surgical procedure at this time. The review has determined that the requested MRI is not medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the foot have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the foot.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing for Carbamazepin (80157), Levetiracetam (80177), Topiramate (80201), Digoxin (80162), Clozapine (80159), and Haloperidol (80173) provided on March 29, 2021.
You asked the Plan to pay for testing for Carbamazepin, Levetiracetam, Topiramate, Digoxin, Clozapine, and Haloperidol. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 80157, 80159, 80162, 80173, 80177, 80201 are not supported in the medical record. Specifically, testing for these specific individual drugs is not documented in the records. Based on this information, we decided that Medicare rules for coverage of testing for Carbamazepin, Levetiracetam, Topiramate, Digoxin, Clozapine, and Haloperidol have not been met. Therefore, we decided that the Plan does not have to pay for testing for Carbamazepin (80157), Levetiracetam (80177), Topiramate (80201), Digoxin (80162), Clozapine (80159), and Haloperidol (80173) provided on March 29, 2021
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).  You asked the Plan to pre-approve the PETCT scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says that the requested service is not medically necessary criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PETCT scan. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a history of thyroid cancer treated with thyroidectomy and ablation in 2013. The record indicates that the enrollee's thyroglobulin level increased over the past year. The record indicates that the enrollee s being actively treated with thyrogen and the requested test is to monitor response to treatment. The elements of the coverage rule are satisfied, and the requested service is recommended.  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 PETCT scan have been met. Therefore, we decided that the Plan has to pre-approve Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).   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 waive the copayment for a specialist office visit provided by on August 19, 2021.  You asked the Plan to waive the copayment for a specialist office visit. You say that the visit was a follow up and should not have a copayment. The Plan denied your request. The Plan says the proper copayment was applied 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 $35 copayment for each Medicare-covered specialist visit.     You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided by on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on August 31, 2021.  You asked the Plan to pay for code 70544. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that 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 the Magnetic resonance angiography (70544) provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on October 7, 2021.  You asked the Plan to pay for the periodic oral evaluation. You say that you went in for a regular 6-month preventive visit with a cleaning. The Plan denied your request. The Plan says the limitation for oral exams has been met/paid for the benefit year. The Plan also says that there were no calls to the Plan to verify if your exams benefit had been maxed.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to two preventive exams every calendar year. The record shows that you received a comprehensive oral evaluation (D0150) on March 9, 2021, and a comprehensive periodontal evaluation (D0180) on April 20, 2021, and your preventive exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant360 testing provided on August 12, 2021.  You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this testing is medically necessary to guide the treatment for the member's condition. The Plan denied your request. The Plan says this testing does not meet Medicare criteria for coverage.  The Plan follows Medicare rules. Medicare rules say that Guardant360 remains covered for patients with non-CNS originated solid tumors who meet the criteria listed in the Medicare rules section of this letter.  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 Guardant360 testing. Our reviewer says that this testing is not medically reasonable or necessary. Our physician reviewer found Guardant360 liquid biopsy is indicated for advanced cancers when tissue testing is not available to guide treatment decision making in some cancers. For breast cancer being treated as first line therapy next generation sequencing/molecular profiling would not be a standard for 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 the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient visit (99213) provided on October 4, 2021.  You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate that a different anatomical site, a different condition or a related but unusual condition was addressed during the osteopathic manipulation visit.  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 99213 is  office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.   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 outpatient visit. Our reviewer says that CPT code 99213 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that 99213 performed on October 4, 2021 was a distinct separate service unrelated to the osteopathic manipulation visit, also performed on October 4, 2021, therefore, it is inappropriate to submit 99213 with a 25 modifier as this service is not eligible for separate reimbursement.  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 outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient visit (99213) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that the in-network doctors have to make outreach to the requested provider. The Plan denied your request. The Plan says this is available in-network.  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 an office visit to be provided by an out-of-network (OON) provider.
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 the intensity of services provided at an IRF.  Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation.  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.