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

We decided that the Plan does not have to pre-approve a cervical facet joint injection.
You asked the Plan to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or
thoracic; single level (64490). You say that radiofrequency ablation is not 100% effective, expensive and has
side effects. The Plan denied your request. The Plan says there is no plan for RFA.
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 injection(s), diagnostic or therapeutic
agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT), cervical or thoracic; single level (64490). Our reviewer says that the requested services
are not considered medically reasonable and necessary in this case. Our physician reviewer found that per the
coverage criteria, the enrollee should undergo radiofrequency ablation. The review has determined that the
requested cervical facet injections are 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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal)
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single
level (64490) have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical
facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on May 7, 2021.
You asked the Plan to waive the copayment for the dermatology visit. You say that you were told by the doctor's office that there would be no charge for the first procedure. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for visits with a specialist. You have been asked to pay a $20 copayment for the dermatology visit. The dermatology visit falls within the visits with a specialist benefit category. This copayment applies regardless of the services received. There is no provision in your contract for a waiver of this amount, even if this was your first procedure. 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 dermatology visit you had on May 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography testing (95811).
You asked the Plan to pre-approve polysomnography testing. You say that this sleep study is medically necessary for the enrollee. The Plan denied your request. The Plan says the criteria for the requested sleep study are not met. The Plan follows 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 polysomnography testing. Our reviewer says that the requested polysomnography is not medically necessary and does not meet Medicare criteria for coverage. Our physician reviewer found in this case, there is no documentation of significant weight change, either loss or gain. The enrollee tried a continuous positive airway pressure (CPAP) in the past, but it made the enrollee feel worse rather than better. There are no notes showing the enrollee had desensitization to the CPAP or bilevel mask. Notes state that desensitization will be scheduled prior to repeat study for CPAP/bilevel titration to improve the compliance of the usage of the CPAP/bilevel. No documentation was provided of this scheduled/completed desensitization, nor was there documentation of an outcome or compliance with the CPAP machine after desensitization. Criteria are not met 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 polysomnography testing have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography testing (95811).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of a nursing facility patient (99380) provided on March 29, 2021.
You asked the Plan to pay for the supervision of a nursing facility patient. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no separate payment is made per Medicare.
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 99380 is supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.
We find that CPT code 99380 is not eligible for payment. Specifically, the Physician Fee Schedule lists the status code as "B" which is a bundled code. Payment for covered services which a status code of "B" are always bundled into payment for other services for specified. Based on this information, we decided that Medicare rules for coverage of the supervision of a nursing facility patient have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility patient (99380) provided on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport provided on March
30, 2021.
You asked the Plan to waive the copayment for an ambulance transport. You say that you did not receive the
first notice. The Plan denied your request. The Plan says you have been asked to pay the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that enrollees must pay a
$125 copayment for each one-way ambulance transport.
You have been asked to pay a $125 copayment for an ambulance transport. An ambulance transport falls within
the Ambulance Services benefit category. This means that you have been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an
ambulance transport provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on April 23, 2021.

You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says there was no face to face examination within the last six months from the treating physician.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on April 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for medical examination (92012) and scanning computerized ophthalmic diagnostic imaging (92133), provided on April 9, 2021.
You asked the Plan to waive the copayment for medical examination and scanning computerized ophthalmic diagnostic imaging. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare-covered diagnostic radiology services for Outpatient diagnostic tests and therapeutic services and supplies and $40 for specialist visits. You have been asked to pay $28.87 out of the $50 copayment for Medicare-covered diagnostic radiology services for scanning computerized ophthalmic diagnostic imaging and $40 for the medical examination. 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 medical examination (92012) and scanning computerized ophthalmic diagnostic imaging (92133), provided on April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 15, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 15, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from October 15, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 15, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond October 15, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from October 15, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 15, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on April 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable oxygen concentrator. You say that you were told that your machine would take five months to repair. The Plan denied your request. The Plan says the item received is not a covered benefit when provided by an OON provider.
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 portable oxygen concentrator provided on April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 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 code 27495 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 27495 is prophylactic treatment (nailing, pinning, plating,
or wiring) with or without methyl methacrylate, femur.

We find that CPT code 27495 is not supported in the medical record. Specifically, the records show that
prophylactic treatment of an impending pathological fracture of the proximal femur was performed and there is
a more appropriate code for these services. 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
surgical services rendered on March 26, 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. Continued care in the acute inpatient rehabilitation facility is appropriate (and endorsed by the health plan) until you are stable to transfer to a lower level of care such as home with home health services or to an assisted living facility or long term care facility with part time services. 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: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services provided on March 7, 2021.

You asked the Plan to waive the copayment for the emergency department services. You say that the enrollee does not like the way he was treated and will not pay the bill. The Plan denied your request. The Plan says the enrollee was charged the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for Emergency Care.
The enrollee has been asked to pay a $90 copayment for the emergency department services. The emergency department services fall within the Emergency Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department services provided on March 7, 2021.

Your complaint is not a valid appeal for medical coverage. Your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detections by nucleic acid (U0003 and
U0005) provided on January 26, 2021, and February 2, 2021.
You asked the Plan to pay for the infectious agent detections. You say that you would like this claim to be
reconsidered. The Plan denied your request. The Plan says the enrollee was active on hospice at the time of
service and payment is the responsibility of 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 the infectious agent detections by nucleic acid (U0003 and
U0005) provided on January 26, 2021, and February 2, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray (71045) provided on June 1, 2021.

You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says that this is not separately payable from code 77001.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. While the Plan has stated that code 71045 cannot be paid separately from code 77001 without a modifier, code 77001 is not present on the claim for 71045 and the Plan has not submitted any additional claims from this date of service to show this code was billed. Without documentation showing that 77001 was also billed, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for an x-ray (71045) provided on June 1, 2021.

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: Partially Favorable

We decided that the Plan has to pay for the radical resection of a tumor. We decided that the Plan does not have to pay for the excision of a parotid tumor or parotid gland.
You asked the Plan to pay for the excision of a parotid tumor or parotid gland and radical resection of a tumor. You say that you would like reconsideration based on the records submitted. The Plan says that the documentation submitted does not support the services billed.
We decided that the Plan has to pay for the radical resection of a tumor.
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 radical resection of a tumor. Our reviewer says that the documentation supports CPT code 21026. This service is clearly documented in the operative report. 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 radical resection of a tumor have been met. Therefore, we decided that the Plan has to pay for the radical resection of a tumor.
We also decided that the Plan does not have to pay for the excision of a parotid tumor or parotid gland.
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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 excision of a parotid tumor or parotid gland. Our physician reviewer found the documentation does not support the use of CPT code 42415. The operative report did not include documentation of an excision of parotid tumor or parotid gland with dissection and preservation of facial nerve of the lateral lobe; therefore, this code cannot be verified. 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 excision of a parotid tumor or parotid gland have not been met. Therefore, we decided that the Plan does not have to pay for the excision of a parotid tumor or parotid gland.
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.