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

We decided that the Plan does not have to waive the copayment for cataract surgery and
phenylephrine/ketorolac eye solution (a Medicare Part B drug) provided on May 25, 2021.
You asked the Plan to waive the copayment for cataract surgery and Part B drug. You say that you do not
believe you should be charged this amount. The Plan denied your request. The Plan says the copayment amount
you are being charged is correct.
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 $290
copayment for surgery and 20% coinsurance for Part B drug received from an in-network provider. The
allowed amount of the Part B drug is $394.40, resulting in a coinsurance amount of $78.88. Your total costsharing
amount is therefore $368.88.
You have been asked to pay $290 copayment for surgery and 20% coinsurance for Part B drug. Cataract
surgery and Part B drug fall within the "Outpatient Surgery, Including Services Provided at Hospital Outpatient
Facilities and Ambulatory Surgical Centers" and "Medicare Part B Prescription Drugs" benefit categories. 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 cataract surgery and phenylephrine/ketorolac eye solution (a
Medicare Part B drug) provided on May 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room services (99285,
99284) provided May 19, 2020, July 6, 2020, October 7, 2020, October 26, 2020, and March 4, 2021, and the
computed tomography (CT), thorax, diagnostic; with contrast material(s) (71260) provided May 21, 2020.
You asked the Plan to waive the copayments for the emergency room services and CT scan. You say that the
enrollee is not able to afford all the copayments and you would like them lowered or waived. The Plan denied
your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for each covered emergency room visit and a $250 copayment for Medicarecovered
diagnostic radiology services such as CT scans.
The enrollee has been asked to pay a $90 copayment for each emergency room visit and a $250 copayment for
the CT scan. The emergency room services fall within the Emergency services benefit category and the CT
scan falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 copayments for the emergency room services (99285, 99284) provided May 19,
2020, July 6, 2020, October 7, 2020, October 26, 2020, and March 4, 2021, and the computed tomography
(CT), thorax, diagnostic; with contrast material(s) (71260) provided May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 15, 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 Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
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 pay for laboratory services provided to the enrollee on December 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit and Luspatercept-aamt.
You asked the Plan to pre-approve Retacrit and Luspatercept-aamt. You say that the medications 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 a drug or biological only if it is safe and effective and otherwise reasonable and 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 Retacrit and Luspatercept-aamt. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Retacrit and Luspatercept-aamt is medically reasonable and necessary for the enrollee. The documentation does not support that the Retacrit and Luspatercept-aamt is safe and effective 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 Retacrit and Luspatercept-aamt have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit and Luspatercept-aamt.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the drug testing services provided on January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided to the enrollee on February 2, 2021.
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 records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injures patient, first 30-74 minutes." We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not indicate the time spent providing critical care services. 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 pay for critical care services (99291) provided to the enrollee on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on December 10, 2020.
You asked the Plan to pay for Moderate sedation services provided by the same physician or other qualified
health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring
the presence of an independent trained observer to assist in the monitoring of the patient's level of
consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older
(99152) and Moderate sedation services provided by the same physician or other qualified health care
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for
primary service) (99153). You say that the Plan should pay this claim. The Plan denied your request. The Plan
says there is no record of start and stop time for the monitored sedation services or documentation of a trained
observer.
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 code 99152 or CPT code 99153 is not supported in the medical record. Specifically, there is
no documentation of start and stop time nor documentation of a trained observer. Based on this information,
we decided that Medicare rules for coverage of Moderate sedation services have not been met. Therefore, we
decided that the Plan does not have to pay for moderate sedation services provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for embolectomies (34203-59-GC, 34201-59-GC) and aortography (75625-26-59) provided on February 28, 2021.
You asked the Plan to pay for embolectomies and aortography. You say that these codes should be covered. The Plan denied your request. The Plan says these codes are not payable 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, the CPT Code Manual definition of code 34203 is embolectomy or thrombectomy, with or without catheter; popliteal-tibio-peroneal artery, by leg incision. The definition of 34201 is embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision. The definition of 75625is aortography, abdominal, by serialography, 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 embolectomies and aortography. Our reviewer says that these codes are not supported. Our reviewer found while the records support that modifier -59 is appropriate on codes 34203 and 34201, as no thrombectomy was performed, an appropriate modifier is required for decreased services. Code 75625 is not supported because the documentation does not include radiological films with supervision and interpretation. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of embolectomies and aortography have not been met. Therefore, we decided that the Plan does not have to pay for embolectomies (34203-59-GC, 34201-59-GC) and aortography (75625-26-59) provided on February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for
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 appropriate modifier was not 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. We find that CPT codes 95937, 95940 and G0453 is not supported in the medical record. Specifically, an appropriate modifier was not reported allowing these services to be reported unbundled from CPT 51785. 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 pay for
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve conduction test and electromyography you had on March 17, 2021.
You asked the Plan to waive the copayment for the nerve conduction test and electromyography. You say that you saw the provider in the office so you should only have to pay your $5 office visit copayment. 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 $150 copayment for diagnostic procedures and tests (except x-rays). You have been asked to pay a $150 copayment for the nerve conduction test and electromyography. The nerve conduction test and electromyography fall within the diagnostic procedures and tests (except x-rays) 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 nerve conduction test and electromyography you had on March 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone sodium phosphate, Carboplatin,
Paclitaxel, and Keytruda.
You asked the Plan to pre-approve Dexamethasone sodium phosphate, Carboplatin, Paclitaxel, and Keytruda.
You say that the medications 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 a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Dexamethasone sodium phosphate,
Carboplatin, Paclitaxel, and Keytruda. Our reviewer says that the medications are necessary. Our physician
reviewer found you received this regimen already and had progression of disease. Retreatment with the same
regimen is not FDA approved or supported by the medical literature. After progression, retreatment with the
same regimen is unlikely to be effective and likely to have significant toxicities.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Dexamethasone sodium phosphate, Carboplatin, Paclitaxel, and Keytruda have
not been met. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone sodium
phosphate, Carboplatin, Paclitaxel, and Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and imaging services rendered on February 19, 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 codes 36215 and 75710 are 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 36215 is selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. The definition of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation.
We find that procedure codes 36215 and 75710 are not supported in the medical record. Specifically, there is no documentation of selective catheter placement into the arterial system to support code 36215. There is no documentation of a unilateral extremity angiography with radiological supervision and interpretation to support code 75710. 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 and imaging services rendered on February 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 12, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 out of network physician services provided to the enrollee on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99203) provided to the enrollee on February 24, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 the office visit (CPT code 99203) provided to the enrollee on February 24, 2021, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 7, 2021.
You asked the Plan to waive the copayment for emergency room visit. You say that you were told you needed to go to the emergency room. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $90 copayment for emergency room visit. You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency 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 copayment for an emergency room visit provided on April 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 28, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay a $120 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $120 copayment for the emergency room visit provided. 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 room visit provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an influenza screening (87502) provided on April 15, 2021.
You asked the Plan to pay for an influenza screening. You say that this was billed correctly as a screening. The
Plan denied your request. The Plan says this is not a covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, an influenza screening, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for an influenza screening (87502) provided on April 15, 2021.