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

We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure you had at an ambulatory surgical center on June 25, 2021.
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that this is an outpatient diagnostic procedure which should be covered. You believe that the reason for the denial may be because of lack of prior authorization. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($282.61) is less than your copayment obligation, you are responsible for the full allowed 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 $295 copayment for outpatient surgery.
You have been asked to pay a $295 copayment for the cystourethroscopy procedure. The cystourethroscopy procedure falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure you had at an ambulatory surgical center on June 25, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428RH) provided on February 5, 2021.
You asked the Plan to pay for the transportation service. You say that the enrollee was transported 3 times on this date of service. You say that each and every one of these transports were medical necessary. You also say that the enrollee was unable to be transported with any other means of transportation. The Plan denied your request. The Plan says a physician's office is not a covered destination.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 transportation service. Our reviewer says that the transportation service is not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport, such as stretcher van, were contraindicated for the enrollee on February 5, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on February 5, 2021. The reviewer also found that the documentation
does not support that the ambulance transport on February 5, 2021, was medically reasonable and necessary for the enrollee. 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 transportation service have not been met. Specifically, the file does not show that other means of transport, such as stretcher van, were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428RH) provided on February 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the criteria have not been met and it has not been demonstrated that it is medically necessary to make an exception for the enrollee.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug (1) an oral bisphosphonate drug (e.g., Alendronate, Ibandronate, Risedronate) and (2) Zoledronic Acid (generic Reclast) before they will approve the requested drug. Our reviewer found that in this case, the patient has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement (97597) and a home visit (99350) provided on June 8, 2021.
You asked the Plan to pay for debridement and a home visit. You say that this should be covered as in-network. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97597 is debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less We find that CPT codes 97597 and 99350 are not supported in the medical record. Specifically, there is no documentation of debridement in the submitted records to support 97597. Code 99350 is a column II code to column I code 97597. This claim has not been billed with an appropriate modifier to bypass the edit. Based on this information, we decided that Medicare rules for coverage of debridement and a home visit have not been met. Therefore, we decided that the Plan does not have to pay for debridement (97597) and a home visit (99350) provided on June 8, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for myocardial perfusion imaging provided on August 13, 2021.

You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you have never been charged for a stress test in the past and disagree with the charges. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for nuclear medicine. 

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $50 copayment for myocardial perfusion imaging. The Plan contract does not clearly say how much enrollees must pay for nuclear medicine. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for myocardial perfusion imaging provided on August 13, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness, electronic connection, replacement seat cushion cover, and foot plate bracket.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller and harness with electronic connection is used to control multiple power options. The rules say that footplates are described by codes K0040, K0041, or K0042. The rules say that for equipment to be covered, it must primarily serve a medical purpose. We looked at the file and Medicare rules. The requested expandable controller with harness and electronic connection are not needed to control the approved power switches. The footplates were requested under code K0108, which is not appropriate coding for this item. The replacement seat cushion cover does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness, electronic connection, replacement seat cushion cover, and foot plate bracket.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 24, 20219, to January 14, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until March 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 24, 20219, to January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from July 31, 2021, to August 3, 2021.  You asked the Plan to pay for the acute inpatient hospital care. You say that you believe strongly that the services provided to this enrollee were medically necessary and required an inpatient setting. The Plan denied your request. The Plan says that the hospital stay was not medically necessary. The Plan also says that the services could have been safely and effectively managed at a lower level of care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 31, 2021, to August 3, 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: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve blepharoplasty and repair of brow ptosis.  You asked the Plan to pre-approve blepharoplasty and repair of brow ptosis. You say that the record clearly shows that these services are necessary. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because there are no notes or visual field study to show that the enrollee meets coverage criteria.  The Plan follows Medicare rules. Medicare rules say that blepharoplasty and repair of brown ptosis may be covered under certain clinical indications.  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 blepharoplasty and repair of brow ptosis. Our reviewer says that the enrollee meets the Medicare criteria for blepharoplasty and repair of brow ptosis. Our physician reviewer found that the record indicates the enrollee has dermatochalasis. The record indicates the MDR-1 is 1.5 bilaterally. The visual fields demonstrate a greater than 12-degree loss that is correctable with taping. The elements of the coverage criteria are satisfied. 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 blepharoplasty and repair of brow ptosis have been met. Therefore, we decided that the Plan has to pre-approve blepharoplasty and repair of brow ptosis.   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on August 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on August 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound (93979), provided on July 22, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you should not have to pay a copayment. 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 $160 copayment for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay $97.26 out of the $160 copayment for the ultrasound. this service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound (93979), provided on July 22, 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 the enrollee is ventilator dependent and requires ongoing acute services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional accessories for a prosthetic leg (L5980, L5986) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the patient's medical need as the treating medical provider progress note documentation does not support that this enrollee is a K3 ambulator, given the documentation that the enrollee has chronic systolic congestive heart failure and left ventricular ejection fraction 20-25%. The enrollee was evaluated for heart transplant. The enrollee has computed tomography (CT) scan ordered of the chest due to his dyspnea and potential right pleural effusion. There is no discussion in the actual  medical progress notes of the enrollee being at a K3 ambulatory level.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a prosthetic leg (L5980, L5986) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a full thickness skin graft (15221) provided on June 11, 2021, by an out-of-network provider.

You asked the Plan to pay for a full thickness skin graft. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 a full thickness skin graft (15221) provided on June 11, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mastectomy supplies provided on October 14, 2021.
You asked the Plan to waive the coinsurance for the mastectomy supplies. You say that the items 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the mastectomy supplies. These items fall within the durable medical equipment (DME) and related supplies 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 coinsurance for the mastectomy supplies provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services received on April 19, 2021.

You asked the Plan to pay for the services. You say that your doctor suggested the vaccine, because you had been cut and scratched with building materials during a home project. The Plan denied your request. The Plan says the charge for providing this vaccination is not covered when no corresponding vaccine is billed.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services received on April 19, 2021.