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

We decided that the Plan does not have to pre-approve the bone marrow aspiration (CPT code 20939), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 service. 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 specific indication provided to support the request for bone marrow aspirate for the
approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for bone marrow aspirate in the setting of spinal fusion surgery 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the bone marrow aspiration (CPT code 20939), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that the enrollee has scarring in right upper lobe which has increased in size. You state the enrollee is also having pain in the left periumbilical area and is in need of the PET CT to assess for progression for the enrollee's history of lung cancer stage five (5). The Plan denied your request. The Plan says that the requested study would exceed the allowed limit of three (3) scans.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer found the enrollee has an area in the lungs that is growing and more prominent on CT requiring further imaging (PET) to help guide whether or not the enrollee requires more aggressive therapy again. Therefore, repeat PET will be considered 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.

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 available from network providers at the in-network rate.

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 50% of the Medicare-allowed amount per stay for out-of-network SNF care.

The requested provider is out-of-network with the Plan. If the enrollee chooses to receive services with this provider, they will be asked to pay 50% of the Medicare-allowed amount per stay for these services. These services fall within the out-of-network SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. The Plan has network providers available from which the enrollee may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transforaminal epidural injections (64483) provided on January 19, 2021.

You asked the Plan to pay for transforaminal epidural injections. You say that this is supported in the records. The Plan denied your request. The Plan says the billed units exceed MUE.

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 64483 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 transforaminal epidural injections have not been met. Therefore, we decided that the Plan does not have to pay for transforaminal epidural injections (64483) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for ferric carboxymaltose (a Medicare Part B drug) injections and injection administration services provided on January 17, 2021 and January 24, 2021.
You asked the Plan to waive the cost-sharing for Part B drugs and injection administration services. You say that you were told all of your doctors would be covered by the Plan and feel you were totally misinformed. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Part B drugs and $325 copayment for outpatient hospital services. The allowed amounts of the Part B drugs total $1,695, resulting in a total coinsurance amount of $339. For each hospital visit you have been asked to pay the allowed amount of $195.56, because it is less than the $325 copayment for outpatient hospital services. There were 2 visits, resulting in a total copayment amount of $391.12. Therefore, your total cost-sharing obligation is $730.12. You have been asked to pay 20% coinsurance for Part B drugs and less than $325 copayment for outpatient hospital services. Part B drugs and injection administration services fall within the "Medicare Part B Prescription Drugs" and "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-sharing for ferric carboxymaltose (a Medicare Part B drug) injections and injection administration services provided on January 17, 2021 and January 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on December 18, 2020 and December 29, 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 procedure code 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records do not show that a therapeutic procedure to one or more areas for 15 minutes was performed for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on December 18, 2020 and December 29, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 27, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on April 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 19, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were concerned that if you got in the ambulance and went to the hospital, the Plan might not cover the transportation because you were aware that you do not have non-emergency transposition benefits. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport to the nearest appropriate facility there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the PurePap, CPAP cleaner purchased December 31, 2020.
You asked the Plan to pay for the CPAP cleaner. You say that you need the money and you are appealing for reimbursement of the amount of $119.90. You need this to clean bacteria from your CPAP machine. The Plan denied your request. The Plan says CPAP cleaner is not covered by Medicare or the Plan under any condition.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the PurePap, CPAP cleaner purchased December 31, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the services provided from January 1, 2021, to January 31, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were billed incorrectly.

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. We find that the Plan did not submit a compelling denial rationale in this case. The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the SNF services were authorized with a HIPPS code that was calculated at the time that the approval was requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the enrollee's actual condition and the services actually rendered during the statement period of the claim. It would therefore be expected that the billed code would differ from a code that was estimated prior to the services being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are incorrect or not supported, only that the code as a whole was not approved. We find that this denial of payment has not been substantiated. Therefore, we decided that the Plan has to pay for the services provided from January 1, 2021, to January 31, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 6, 2021, to January 7, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $350 copayment for outpatient surgery/outpatient hospital facility. 

You have been asked to pay a $350 copayment for an outpatient surgery. Since an outpatient surgery was provided, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/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 an outpatient surgery provided by a participating provider on January 6, 2021, to January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (CPT 99153, CPT 99245) provided to the enrollee from October 7, 2020 to October 8, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99245 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. Additionally, CPT 99153 has a Professional Component/Technical Component indicator of 3. This indicates that the code is not valid for Medicare purposes. 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 inpatient services (CPT 99153, CPT 99245) provided to the enrollee from October 7, 2020 to October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and the extractions (D7140 x5) received February 16, 2021 from the Medicare opt-out provider.

You asked the Plan to pay for the dental services. You say that you needed these extractions for health reasons to prepare for dentures and to prevent heart issues. The Plan denied your request. The Plan says services provided by Medicare opt-out providers are only covered when receiving Emergency care or Urgent care 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. 

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 when they are received from a provider who has opted out of Medicare. The Plan has submitted evidence that the provider in this case has opted out of Original Medicare and does not accept payment from Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and the extractions (D7140 x5) received February 16, 2021 from the Medicare opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on August 24, 2018.

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 filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until May 6, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services rendered on August 24, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015), fundus photography with interpretation and report (92250) and office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making (99203) provided February 7, 2020.

You asked the Plan to pay for the eye refraction, fundus photography and office visit. You say that you did not know the services would not be covered. The Plan denied your request. The Plan says the services were provided out-of-network and therefore are not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by a network provider.

We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of the eye refraction, fundus photography and office visit have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015), fundus photography with interpretation and report (92250) and office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making (99203) provided February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received October 7, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you had a $3,000 dental allowance for 2020, so this service should be paid for. The Plan denied your request. The Plan says this procedure is only covered one procedure every three plan years. You last received this procedure on July 2, 2019.

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 comprehensive oral evaluation, one procedure every three years. 

We looked at the file, and Medicare rules. The Plan has submitted claims evidence that shows this service was last covered by the Plan on July 2, 2019. This service is only covered by the Plan once every three years. When you received this service on October 7, 2020 your benefit was exhausted and you were not eligible to apply your $3,000 dental allowance towards the cost. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received October 7, 2020.