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

We decided that the Plan has to pre-approve myocardial perfusion imaging (78451).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging 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 pre-approve myocardial perfusion imaging. Our reviewer says that the requested imaging service is medically necessary for your condition. Our physician reviewer found that you have multiple risk factors for coronary artery disease (CAD) including diabetes, which is a CAD equivalent. You have had a recent hospital admission for chest discomfort as well and requires testing to rule out ischemia as a cause of her symptoms. You have a very high probability of ischemic heart disease based on her cardiac risk factors including typical symptoms, diabetes, hypertension and hyperlipidemia. Assessment with a highly sensitive non-invasive test is therefore most critical to rule out ischemia. In addition, you have bronchospastic lung disease (on two inhalers) and her exercise tolerance will be limited, and likely non-diagnostic and she will require pharmacologic enhancement for stress testing. This would make stress nuclear imaging medically necessary and reasonable in this clinical situation and would meet the criteria of the specific LCD as cited in the Medicare rules section. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging (78451).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the insert tray supply received on June 10,
2021.
You asked the Plan to waive the coinsurance for the insert tray supply. You say that since the provider forgot to
include this item in your first shipment, you should not have to pay this coinsurance. The Plan denied your
request. The Plan says this coinsurance was charged 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 20% coinsurance for prosthetic devices and supplies.
The enrollee has been asked to pay 20% coinsurance for the insert tray supply. The insert tray supply falls
within the prosthetic devices and supplies benefit category. This coinsurance applies regardless of when the
enrollee receives the item. 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 coinsurance for the insert tray supply
received on June 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on March 15,
2021, by an OON provider.

You asked the Plan to pay for the interrogation device evaluation. You say that the service was medically
necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the interrogation device evaluation provided on March 15, 2021,
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays (73600, 73630) provided May 6, 2021.

You asked the Plan to pay for the x-rays. You say that the services should be covered. The Plan denied your request. The Plan says the deductible was not met at the time the services were rendered. The correct cost-sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible which applies to radiology services. 

The item or service you asked the Plan to pay for falls within the benefit category radiology services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to radiology services. This cost sharing is a contractual obligation that had not been met at the time the x-rays was received on May 6, 2021. Therefore, we decided that the Plan does not have to pay for x-rays (73600, 73630) provided May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast biopsy (19083) provided on
April 5, 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 you must pay a $370
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $370 copayment for the Medicare-covered surgery provided at an outpatient
hospital. 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 breast biopsy (19083) provided on
April 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on May 12, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the Cologuard test resulted in a false positive, so you should not have to pay the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you had a Cologuard test on March 24, 2021. Due to the results of that test, you were advised to have a diagnostic colonoscopy.

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 $200 copayment for outpatient surgery or services at an ambulatory surgery center or outpatient hospital facility. 

You have been asked to pay a $200 copayment for the diagnostic colonoscopy. Because you had already received a covered colorectal cancer screening test (i.e., the Cologuard test), the colonoscopy you received was ordered not as a screening, but as a diagnostic service. That is why the diagnostic colonoscopy falls within the outpatient surgery or services at an ambulatory surgery center or outpatient hospital facility 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 diagnostic colonoscopy you had on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on December 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the services billed are covered services because they are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent and that there was no referring provider. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on December 28, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP) device to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a CPAP device. You say that you would like to stay with the same provider. The Plan denied your request. The Plan says there are in-network providers available to meet your medical needs.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure device (CPAP) device to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repair of leg tendon.
You asked the Plan to pre-approve the repair of leg tendon. You say that this procedure is medically necessary. The Plan denied your request. The Plan says this surgery is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the repair of leg tendon. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the magnetic resonance imaging (MRI) study does not show a tendon tear injury. Criteria for tendon repair surgery in the lower leg and ankle region is not met. 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 repair of leg tendon have not been met. Therefore, we decided that the Plan does not have to pre-approve the repair of leg tendon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve a CPAP device. You say that this requested item is medically necessary. The Plan denied your request. The Plan says you have already been provided a CPAP machine and a second would be considered a convenience item.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a standard CPAP device. This equipment serves the same purpose as a CPAP device. Therefore, we decided that the Plan does not have to pre-approve a second continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials coded as 99072 provided on March 1, 2020.

You asked the Plan to pay for the additional supplies and materials. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these are bundled services and not eligible for reimbursement.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials coded as 99072 provided on March 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81493) provided September 16, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the service at issue is non-covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that this test does not meet Medicare's reasonable and necessary criteria for coverage. We looked at the file and Medicare rules. The Corus CAD genetic testing is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81493) provided September 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections of the cervical or thoracic levels represented by
codes 64490 and 64491 provided on March 29, 2021.

You asked the Plan to pay for codes 64490 and 64491. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 64490 is Injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or
CT), cervical or thoracic; single level.

We find that CPT code 64490 is not supported in the medical record. Specifically, the records do not indicate
that injection of cervical or thoracic levels was performed. As the primary procedure code is not covered, the
add-on code of 64491 is not separately payable. Based on this information, we decided that Medicare rules for
coverage of codes 64490 and 64491 have not been met. Therefore, we decided that the Plan does not have to
pay for the injections of the cervical or thoracic levels represented by codes 64490 and 64491 provided on
March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pathology services you received on May 3, 2021.

You asked the Plan to waive the copayment for the pathology services. You say that you had a screening colonoscopy, so there should be no copayment. The Plan denied your request. The Plan says there was no copayment for the colonoscopy itself. The colonoscopy resulted in a polyp being sent to pathology for analysis. The Plan says that you were charged the copayment for the pathology services correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for lab services. 

You have been asked to pay a $20 copayment for the pathology services. The pathology services fall within the lab 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 pathology services you received on May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolastin-C injections (213961, 96365, J0256).

You asked the Plan to pre-approve Prolastin-C. You say that the injections are medically necessary. The Plan
denied your request. The Plan says 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 Prolastin-C. Our reviewer says that the
injections are not medically necessary. Our physician reviewer found the enrollee's age is outside of the
recommended range for Prolastin-C, as stated in Clinical Pharmacology. Safety and efficacy have not been
established in geriatric patients.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolastin-C have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolastin-C injections (213961, 96365, J0256).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 28, 2021.
You asked the Plan to waive the copayment for the ambulance 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for the ambulance 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 ambulance services you received on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV infusion therapy services provided on October 14, 2020 to December 22, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the IV infusion therapy services. You say that this service is not available in-network and that you were not told that you needed to obtain authorization. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 IV infusion therapy services provided on October 14, 2020 to December 22, 2020 by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pelvic and abdominal ultrasounds you had on April 2, 2021.
You asked the Plan to waive the copayment for the ultrasounds. You say that you do not agree with the amount being charged. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it is handling your appeals for the two $15 copayments charged in separate cases.
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 $110 copayment for diagnostic radiology services. You have been asked to pay a $110 copayment for the ultrasounds. The ultrasounds fall within the diagnostic 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 the pelvic and abdominal ultrasounds you had on April 2, 2021.