Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cardiac rehab services (93797) provided on June 10, 2021.  You asked the Plan to waive the copayment for cardiac rehab services. You say that this service was not provided, and you should not have to pay for it. The Plan denied your request. The Plan says medical records were provided to support the services as billed. These records also included an Outpatient Coinsurance Notice with your signature which shows that you are responsible for a $25 copayment for services. This claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $25 copayment for cardiac rehabilitation services.   You have been asked to pay a $25 copayment for cardiac rehab 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 the cardiac rehab services (93797) provided on June 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.

You asked the Plan to pre-approve Eliquis. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.

Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99334) provided on August 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered 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 domiciliary or rest home visit (99334) provided on August 14, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical fusion surgery.

You asked the Plan to pre-approve cervical fusion surgery. 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 cervical fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for cervical fusion surgery at levels C5-C6 (anterior cervical discectomy and fusion) is not medically reasonable or 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 cervical fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee synovectomy (29876) provided on May 21, 2021.  

You asked the Plan to pay for the knee synovectomy (29876). You say that you are to be reimbursed 100% of Medicare's local fee schedule which allows $3,066.67 for this claim. You say that the allowed amount is in correct and the claim should be reprocessed to pay accordingly. The Plan denied your request. The Plan says a major knee synovectomy is included in the more extensive arthroscopic abrasion arthroplasty and only the most extensive procedure should be reported.  

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 29876 is arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral).  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee synovectomy (29876). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that CPT code 29876 may be reported for a medically reasonable and necessary synovectomy with another arthroscopic knee procedure if the synovectomy is performed in 2 compartments on which another arthroscopic procedure is not performed. The operative report describes arthroplasty and synovectomy in the patellofemoral joint; the arthroplasty and synovectomy was performed in medial compartment; the synovectomy was performed in lateral compartment. The documentation does not document medically necessity for Synovectomy and only 1 compartment had a synovectomy performed. Therefore, this does not meet the criteria per Medicare guidelines.   

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee synovectomy (29876) have not been met. Therefore, we decided that the Plan does not have to pay for the knee synovectomy (29876) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on July 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a domiciliary or rest home visit. You say that this was medically necessary, and the facility should have obtained authorization. The Plan denied your request. The Plan says this was 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 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 domiciliary or rest home visit (99336) provided on July 13, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on June 14, 2021.  You asked the Plan to pay for laboratory services. You say that there is no contractual agreement to include these services in the dialysis rate. The Plan denied your request. The Plan says these services are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System (PPS) as Part B services and are not paid separately.  We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of ESRD and are not paid separately from the ESRD PPS. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on October 18, 2021.  You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you feel that the 10 minute phone call should not be billed the same as an office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each telehealth specialist visit.   You have been asked to pay a $30 copayment for the specialist telehealth visit. Specialist telehealth visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on May 27, 2021 by an out-of-network (OON) provider.  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 were 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 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 provided on May 27, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (72275) provided July 7, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72275 is a column II code to column I code 64483. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for lab services (72275) provided July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolotherapy with nerve stimulation (96372, 97016, 97112, 97139, J3411, J3415, J3490, J7999) provided September 14, 2021.  You asked the Plan to pre-approve the Prolotherapy with nerve stimulation. You say that the treatments provided were medically necessary. The Plan denied your request. The Plan says these services are experimental in nature and non-covered.  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 Prolotherapy with nerve stimulation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. Prolotherapy is an investigational therapy. It is noted that larger, randomized trials are needed to assess this treatment.  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 Prolotherapy with nerve stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolotherapy with nerve stimulation (96372, 97016, 97112, 97139, J3411, J3415, J3490, J7999) provided September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on August 27, 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 covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on August 27, 2021.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.  

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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasound (76642) provided March 9, 2021.  

You asked the Plan to pay for the ultrasound. You say that multiple exams were performed on the same date of service. The Plan denied your request. The Plan says the documentation does not support more units of this service. The records submitted are duplicates.  

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  

We find that 2 units of CPT code 76642 are not supported in the medical record. The medical record only supports 1 unit of CPT code 76642. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76642) provided March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on September 16, 2021.

You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your request. The Plan says there is no coverage for out-of-network services.

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. The Plan covers the services when the services are provided by a network provider. 

The rendering provider was not participating with the dental plan. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for laparoscopy, surgical; cholecystectomy with cholangiography (47563) provided December 30, 2020.  You asked the Plan to pay for the surgical services. You say that this medical provider supplied surgical services in good faith and the insurance funds received have been exhausted. You cannot be held liable for mistakes of the payer. The Plan denied your request. The Plan says per Medicare, this provider cannot be reimbursed.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for laparoscopy, surgical; cholecystectomy with cholangiography (47563) provided December 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skin substitute treatment (Q4133, 15275, 15276).  You asked the Plan to pre-approve skin substitute treatment. You say that the requested skin substitute treatment is medically necessary. The Plan denied your request. The Plan says the requested skin substitute treatment does not meet criteria.  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 skin substitute treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the most recent visit stated that the wound is getting better. The enrollee underwent sharp debridement of fungal nail and the toe wound again.  The documentation does not support coverage for the skin substitute treatment which is not medically necessary or reasonable for a chronic wound that is healing with current management.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin substitute treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve skin substitute treatment (Q4133, 15275, 15276).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99202) and the destruction of benign lesions (17110) rendered by the out-of-network (OON) provider on September 23, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 office visit (99202) and the destruction of benign lesions (17110) rendered by the out-of-network (OON) provider on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complex cataract surgery (66982) provided on July 14, 2021.  You asked the Plan to pay for the complex cataract surgery. You say that this surgery is supported by the medical records submitted. The Plan denied your request. The Plan says the service was not medically necessary.  The Plan follows Medicare rules. Medicare rules say that complex cataract surgery is subject to the criteria listed in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the complex cataract surgery. Our reviewer says that the documentation does not support the billing of complex cataract surgery. Our physician reviewer found the enrollee underwent cataract surgery.  The operative report provided does not indicate a justification for the CPT descriptor. The operative note does not document a complex cataract repair. The elements of the coverage criteria are not satisfied.  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 complex cataract surgery have not been met. Therefore, we decided that the Plan does not have to pay for the complex cataract surgery (66982) provided on July 14, 2021.