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

 We decided that the Plan does not have to reduce the copayment for the ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation (76536) provided August 18, 2021.  You asked the Plan to reduce the copayment for the ultrasound. You say that you believe your copayment should be $30. The Plan denied your request. The Plan says the copayment 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 $105 copayment for Medicare-covered radiological diagnostic services, not including X-rays performed in a physician's office or at a free-standing facility.  You have been asked to pay a $105 copayment for the ultrasound. The ultrasound 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 reduce the copayment for the ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation (76536) provided August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from March 12, 2020, through March 19, 2020, as billed with a secondary diagnosis code of A41.9.  You asked the Plan to pay for the inpatient hospital care as billed. You say that the secondary diagnosis code A41.9 is supported by the medical documentation. The Plan denied your request. The Plan says the medical documentation does not support the inpatient care as billed.  The Plan must follow Medicare rules. 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, you billed the inpatient services provided with secondary diagnosis code, A41.9 defined as sepsis, unspecified organism. 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 inpatient hospital care as billed. Our reviewer says that the documentation does not support the billing of secondary diagnosis code A41.9 defined as sepsis, unspecified organism. Our physician reviewer found that patient is a 68-year-old female who was admitted to the hospital with nausea, vomiting, abdominal pain. A secondary diagnosis code A41.9 defined as sepsis, unspecified organism was utilized as associated with this admission. However, the records did not clearly show evidence of a severe infection causing organ damage or instability that might meet criteria for sepsis. Therefore, the documentation does not sufficiently support the secondary diagnosis code A41.9 defined as sepsis, unspecified organism.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from March 12, 2020, through March 19, 2020, as billed with a secondary diagnosis code of A41.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a breast reduction.  You asked the Plan to pre-approve a breast reduction. You say that the requested breast reduction is medically necessary. The Plan denied your request. The Plan says the requested breast reduction is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no medical records provided to determine if the requested breast reduction is medically necessary. Therefore, we decided that the Plan does not have to pre-approve a breast reduction.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on November 24, 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 services are not covered.  The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with previous negative prostate biopsy who are being considered for repeat biopsy.  We looked at the file and Medicare rules. There is no documentation of a prior prostate biopsy for the enrollee. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) provided on September 23, 2021 by an oral surgeon.  You asked the Plan to waive the copayment for the office visit. You say that this was a visit for a preliminary examination for extraction of teeth. You say that this was not a specialist office visit under the Medical Plan. You also say that you were told the provider will re-file with the Dental Plan and the charge will be removed when they accept the claim. The Plan denied your request. The Plan says there is a $50 copayment for a specialist visit. The Plan also says that the correct cost share amount 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 $50 copayment for a specialist visit under Physician/Practitioner services, including doctor's office visits.   You have been asked to pay a $50 copayment for the office visit. The office visit falls within the Specialist visit under 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 the outpatient office visit (99203) provided on September 23, 2021 by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient behavioral services provided from March 25, 2021, to July 7, 2021.  You asked the Plan to pay for the inpatient behavioral services provided from March 25, 2021, to July 7, 2021. You say that the services were medically necessary. The Plan denied your request. The Plan says that the claim was denied correctly.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide the medical records for this case. We asked for them, but it was not provided to us. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the inpatient behavioral services provided from March 25, 2021, to July 7, 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: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain.  You asked the Plan to pre-approve the brain MRI. You say that you have had symptoms that your treating physician feels could represent brain metastases. You feel that this imaging is needed to check for spread of your disease. The Plan denied your request. The Plan says that there are no documented new central nervous system symptoms for which this imaging would be warranted.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the brain MRI. Our reviewer says that the documentation supports that the requested imaging is medically reasonable and necessary. Our physician reviewer found the enrollee has a history of metastatic breast cancer in active treatment and presents with new neurologic complaints suggestive of brain involvement. Breast cancer can spread to the brain at later stages both as brain metastases and leptomeningeal spread. A brain MRI is the best test to evaluate for this.  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 brain MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain.   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 services provided to you by an out-of-network provider on July 12, 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 to you by an out-of-network provider on July 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for interoperative monitoring services (95939-TC, 95938-TC, 95861-TC, 95955-TC, 95937-TC, 95908-TC) provided on July 30, 2021.  

You asked the Plan to pay for interoperative monitoring services. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.  

The Plan must follow Medicare rules.  

Medicare rules say that payment is not made under the physician fee schedule for Technical Component (TC) services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings.  

We looked at the file and Medicare rules. The services at issue were billed with modifier TC for the technical component, but the record indicates these services were provided in an inpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of interoperative monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for interoperative monitoring services (95939-TC, 95938-TC, 95861-TC, 95955-TC, 95937-TC, 95908-TC) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (88325) provided on July 29, 2021.  

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.  

 In this case, the MUE for CPT code 88325 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 services (88325) provided on July 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vascular embolization (37242) provided on May 9, 2021.  You asked the Plan to pay for the vascular embolization (37242). You say that the operative report should be reviewed and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 37242 is not supported by the medical records.  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 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms).  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 vascular embolization (37242). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not include documentation of a vascular embolization or occlusion and CPT 37242 is an incorrect procedure code to report for this service.  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 vascular embolization (37242) have not been met. Therefore, we decided that the Plan does not have to pay for the vascular embolization (37242) provided on May 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genicular nerve block provided on September 10, 2021.  You asked the Plan to pay for the genicular nerve block. You say that the genicular nerve block provided on September 10, 2021, was medically necessary. The Plan denied your request. The Plan says the genicular nerve block provided on September 10, 2021, was 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 pay for the genicular nerve block. Our reviewer says that the genicular nerve block provided on September 10, 2021, was not medically necessary. Our physician reviewer found the enrollee is with chronic right knee pain due to primary osteoarthritis. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are considered experimental/investigational in nature. The blocks are not reasonable or 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 the genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block provided on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on July 21, 2021.  You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the orthoses billed for provided on April 8, 2021.  You asked the Plan to pay for the billed items. The Plan denied your request. The Plan says there is insufficient documentation do corroborate the services.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The file shows that a cervical collar and shoulder-to-hand orthosis was billed on the date of service at issue. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the orthoses billed for provided on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee is still completing their course of care at the acute hospital, and these services have not been denied. At this time, the enrollee is not clinically stable for an IRF level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for you. The Plan denied your request. The Plan says that the request for a home mechanical ventilator with settings that could be delivered by BiPAP with average volume-assured pressure support for the enrollee is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. The patient has COPD. Arterial blood gas (ABG) was essentially normal. There was insufficient documentation showing the patient required mechanical ventilation or that he used a positive airway pressure device in the hospital to justify this request.  Throughout the hospital his pulse oximetry was normal. Our physician reviewer found that your condition does not meet Medicare criteria for a portable ventilator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost for the denosumab injection and therapeutic injection provided on July 28, 2021.  You asked the Plan to waive the cost for the denosumab injection and therapeutic injection. You say that the bill is supposed to be paid by Medicare. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each Medicare-covered Part B drug. Your contract with the Plan clearly says that you must pay a $280 copayment for Medicare- covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay a total of $245.81 for the denosumab injection and therapeutic injection.   Service Allowed Amount Standard Cost Member Liability Denosumab Injection $919.98 20% $184 Therapeutic Injection $61.81 $280 $61.81 TOTAL:   $245.81  The denosumab injection falls within the "Medicare Part B Prescription Drugs" benefit category. The therapeutic injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 cost for the denosumab injection and therapeutic injection provided on July 28, 2021.