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

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging.

You asked the Plan to pre-approve gastrointestinal tract imaging. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 gastrointestinal tract imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided record does not support the medical reasonableness or necessity of the requested service for your clinical condition. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 gastrointestinal tract imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal tract imaging.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (74176) provided on April 5, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-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 service 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 radiology services (74176) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device).
You asked the Plan to pre-approve bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device). You say that the requested bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device) is medically necessary. The Plan denied your request. The Plan says that the requested bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device) is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device). Our reviewer says that the requested bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device) is medically necessary. Our physician reviewer found bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. Bioimpedance spectroscopy is used for diagnosis as well as assessing treatment response. Bioimpedance spectroscopy (BIS) is an increasingly utilized diagnostic technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard of care. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device) have been met. Therefore, we decided that the Plan has to pre-approve the bioimpedance spectroscopy, extracellular fluid analysis for lymphedema assessment (ImpediMed L-Dex testing device).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 2, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 13. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast reconstruction procedure to be billed under code S2068.
You asked the Plan to pre-approve a breast reconstruction procedure to be billed under code S2068. You say that the services are necessary. The Plan denied your request. The Plan says code S2068 has a status indicator of "I", which indicates that this service is not valid for Medicare purposes. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a breast reconstruction procedure to be billed under code S2068 have not been met. Therefore, we decided that the Plan does not have to pre-approve a breast reconstruction procedure to be billed under code S2068.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) rendered by the
out-of-network (OON) provider on November 11, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment
(98941) rendered by the out-of-network (OON) provider on November 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a video Electroencephalogram (95714) provided April 10,
2021 to April 12, 2021.

You asked the Plan to pay for the video Electroencephalogram. You say that the services were medically
necessary. The Plan denied your request. The Plan says the documents do not support the billed services.

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 95714 is Electroencephalogram with video (VEEG),
review of data, technical description by EEG technologist, each increment of 12-26 hours.

We find that CPT code 95714 is not supported in the medical record. Specifically, the records do not show that
there was a video component to this service. Based on this information, we decided that Medicare rules for
coverage of the video Electroencephalogram have not been met. Therefore, we decided that the Plan does not
have to pay for a video Electroencephalogram (95714) provided April 10, 2021 to April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic care for treatment of whiplash provided on April
8, 2021.
You asked the Plan to pay for these services. You say that you have been treated for two years for whiplash and
it was always paid before. The Plan denied your request. The Plan says the services provided are not covered
by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance
care. Based on the records provided this is maintenance care for an injury over two years ago. Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
chiropractic care for treatment of whiplash provided on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 3, 2021 and billed under codes 70450 and 70496.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says codes 70450 and 70496 were billed separately for the same date of service which is not allowed on Medicare claims without an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to the absence of a modifier allowing these codes to be separately billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on May 3, 2021 and billed under codes 70450 and 70496.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the inpatient hospital services provided
from August 27, 2019, through September 2, 2019 with a reported principal diagnosis of A41.51.
You asked the Plan to make additional payment for the inpatient services as billed. You say that the incorrect
per diem rates were used to pay this claim. The Plan denied your request. The Plan says records were not
submitted to support the principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation
in order to verify the amount of payment due. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, the DRG was calculated with the use of A41.51 (Sepsis due to Escherichia coli [E. coli]) as the
principal diagnosis. Records were requested through a post-payment review to verify this diagnosis code. No
records were submitted. As such, we cannot verify whether this diagnosis is valid for this claim. Therefore, we
decided that the Plan does not have to make additional payment for the inpatient hospital services provided
from August 27, 2019, through September 2, 2019 with a reported principal diagnosis of A41.51
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the impression and preparation of an oral surgical splint provided on May 20, 2020, billed with code 21085.
You asked the Plan to pay for the splint preparation. You say that the enrollee needs both the airway oral appliance for sleep apnea but also the splint to allow for better positioning of the jaw. The Plan denied your request. The Plan says the code 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 21085 is Impression and custom preparation; oral surgical splint. We find that CPT code 21085 is not supported in the medical record. Specifically, there is no documentation
from the billed date of service showing that impression and custom preparation was done by the billing provider. Based on this information, we decided that Medicare rules for coverage of the splint preparation have not been met. Therefore, we decided that the Plan does not have to pay for the impression and preparation of an oral surgical splint provided on May 20, 2020, billed with code 21085.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 5, 2021, to May 10, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this 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 $295 copayment per day for days 1-6 for inpatient hospital care. 

Records show that you were in the hospital for five days. You have been asked to pay a $295 copayment per day for the inpatient hospital services. 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 inpatient hospital services you received from May 5, 2021, to May 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone imaging you received on November 25, 2020.
You asked the Plan to waive the copayment for the bone imaging. You say that you do not agree with this 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 and nuclear medicine radiological services. You have been asked to pay a $150 copayment for the bone imaging. The bone imaging falls within the diagnostic and nuclear medicine radiological 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 the bone imaging you received on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 documentation does not support that the laboratory services were not provided for screening purposes. This means that the laboratory testing at issue in this appeal 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 the laboratory services provided on January 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385) provided on March 3, 2021.
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 there is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. Furthermore, a screening colonoscopy can become a diagnostic colonoscopy when the screening colonoscopy results in the biopsy or removal of a lesion or growth, or when the biopsy or removal happens during the same visit as the screening colonoscopy. You will be expected to pay different cost sharing when the colonoscopy is considered diagnostic. You may refer to the outpatient surgery section of the Plan contract for cost sharing information. You must pay a $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the diagnostic colonoscopy provided at the ambulatory surgical center. This service falls within the outpatient surgery benefit category as a polyp was removed during this 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 colonoscopy with lesion removal (45385) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ablation procedure (64625) provided May 5, 2021.

You asked the Plan to pay for the ablation procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 

We looked at the file and Medicare rules. The procedure at issue is considered investigational and is non-covered. Based on this information, we decided that Medicare rules for coverage of the ablation procedure have not been met. Therefore, we decided that the Plan does not have to pay for an ablation procedure (64625) provided May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal pontic.
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 a covered benefit.
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 pre-approve a porcelain fused to high noble metal pontic.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Eylea injection you received on April 8, 2021.

You asked the Plan to waive the coinsurance for the Eylea injection. You say that you feel as though this coinsurance should be waived because the cost is too high and because you require this injection four times per year. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the Eylea injection. The Eylea injection falls within the Medicare Part B drugs 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 Eylea injection you received on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan (70470) provided May 14, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment is too high and should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 advanced radiology services. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the advanced radiology 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 a Computed Tomography (CT) scan (70470) provided May 14, 2021.