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

We decided that the Plan does not have to pre-approve a reduction mammaplasty.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary, as you have a great deal of pain. The Plan denied your request. The Plan says this is deemed not medically indicated.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates macromastia due to medical steroid use. The records indicate pain due to the hypertrophy. You weigh 185 pounds with size 40DD breasts. The provided records indicate that the plan is to remove between 250-300 grams per breast, as you wish to achieve a size C cup and symmetry. The provided record does not support that the requested procedure is being performed for reconstructive purposes and is cosmetic in nature. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a reduction mammaplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 7, 2020, to March 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in good faith that reimbursement would be issued. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 skilled nursing services provided on December 7, 2020, to March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging guidance (64625) provided March 25, 2021.
You asked the Plan to pay for the pain management services. You say that medical records are attached for medical necessity review. The Plan denied your request. The Plan says this service is not medically necessary and/or investigational whether performed using traditional, cooled, or pulsed radiofrequency. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pain management services have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation, nerves innervating the sacroiliac joint, with imaging guidance (64625) provided March 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport (A0425, A0427, A0999) provided February 21, 2021.
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the enrollee had a complaint of headache for two days that worsened with turning the neck. The provided record does not support that a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to health. The documentation does not support that the member needed the expertise, services, and lifesaving equipment that only a fully equipped ambulance can provide for safe transport. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport (A0425, A0427, A0999) provided February 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the certified registered nurse anesthetist (CRNA) services provided during a surgical procedure on April 19, 2021, billed with code 01214-QZ.
You asked the Plan to pay for the CRNA services. You say that payment may be made with modifier -QZ when there is no medical direction. In this case, there was only medical supervision. The Plan denied your request. The Plan says that modifier -QZ is not appropriate in cases where there is a physician providing medical direction or supervision.
The Plan follows Medicare rules. Medicare rules say that when a physician is concurrently involved in two to four anesthesia cases and perform the activities listed in the Medicare rules section, he/she is paid at the medically directed rate of 50% of the allowable, and a CRNA may billed with modifier -QX and receive the other 50% of the payment. However, medical supervision occurs when the physician manages more than four procedures, in which case only three base units per procedure may be paid. This is denoted by modifier -AD on the physician claim. The CRNA may report modifier -QZ and receive full payment when there is not medical direction by the physician.
We reviewed the file and the Medicare rules. We found that the definition for the use of modifier -QZ is "CRNA service: without medical direction by a physician". In this case, the physician billed and was paid for medical supervision of this procedure's anesthesia, as -AD was reported. This means that there was no medical direction, as defined by Medicare rules. As such, we find that the use of modifier -QZ by a CRNA under medical supervision only is supported by the rules. Based on this information, we decided that Medicare rules for coverage of the CRNA services have been met. Therefore, we decided that the Plan has to pay for the certified registered nurse anesthetist (CRNA) services provided during a surgical procedure on April 19, 2021, billed with code 01214-QZ.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the oral exam (D0120) and prophylaxis (D1110) provided on April 1, 2021.

You asked the Plan to pay the full amount for the dental services. You say that there is a $0 copayment for preventive dental services that you receive in network or out of network. You also say that your entire bill should be paid. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that if you choose to see an out of network dentist, you might be billed for any amount greater than what the plan pays.

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 and the services are listed as covered, out of network dentists may bill you for any amount greater than what the plan pays. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay the full amount for the oral exam (D0120) and prophylaxis (D1110) provided on April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram provided on March 19, 2021.
You asked the Plan to waive the copayment for the electrocardiogram (93000). You say that you paid your office visit copayment so you should not have a copayment for the electrocardiogram. The Plan denied your request. The Plan says you were charged the $16.75 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 $20 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $16.75 copayment for the electrocardiogram (93000). The electrocardiogram (93000) falls within the Outpatient Diagnostic Tests benefit category. The Medicare allowed amount for this test is $16.75 which is why your required copayment is less. 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 electrocardiogram provided on March 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) provided on January 3, 2021.
You asked the Plan to pay for ambulance response without transport. You say that you needed emergency medical attention, but declined going to the hospital after treatment was provided because you were advised that the hospital was full of patients with COVID-19 and was not particularly safe at the time. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit, and in the event that transportation is not provided, 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 January 3, 2021. The documentation provided for review includes a signed refusal of transportation and a statement from the provider that you were offered transportation and refused the service. 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 ambulance response and treatment without transport (A0998) provided on January 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on March 31, 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 procedure code K0553 may only be billed once every 30 days.
The Plan must follow Medicare rules. The rules say that billing more than 1 unit of service per 30 days of code K0553 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file shows that code K0553 (CGM supplies) was billed more than once every 30 days. 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 continuous glucose monitor (CGM) supplies rendered on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for hemodialysis provided from March 17, 2021 to March 31, 2021.
You asked the Plan to pay for the home visits for hemodialysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis provided from March 17, 2021 to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and an x-ray provided by a participating provider on April 16, 2021.
You asked the Plan to waive the copayment for a specialist office visit and an x-ray. You say that you believe that these charges should be covered because these services were post-op. The Plan denied your request. The Plan says the correct copayments have 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 $45 copayment for physician/practitioner services/in-network/specialist and a $40 copayment for outpatient diagnostic tests/in-network/x-rays. You have been asked to pay a $45 copayment for a specialist office visit. You have been asked to pay $32.36 which is less than your copayment amount of $40 an x-ray. The total amount you are being asked to pay is $77.36 ($45 + $32.36 = $77.36). A specialist office visit falls within the physician/practitioner services/in-network/specialist benefit category. An x-ray falls within the outpatient diagnostic tests/in-network/x-rays 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 office visit and an x-ray provided by a participating provider on April 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy visits (CPT code 97118 x 18) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy visits. You say that you want to use this provider because you have been seeing them multiple times in the past. The Plan denied your request. The Plan says there are in-network providers that can provide the services.
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 the physical therapy visits (CPT code 97118 x 18) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Durolane injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that the office would like to exhaust all non-surgical measures. The Plan denied your request. The Plan says there is no FDA approval for Durolane for shoulder osteoarthritis.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medication is not approved for the treatment of shoulder osteoarthritis. Therefore, the request is deemed 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Durolane injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit you had with a family
medicine doctor on June 14, 2021.
You asked the Plan to waive the deductible for the office visit. You say that this visit was just a wellness check,
and this is higher than you have ever paid for this service in the past. The Plan denied your request. The Plan
says you had not met your deductible at the time of the service.
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 $225 deductible which applies to medical services.
The deductible applies to the office visit you had. The Plan has followed Medicare rules by clearly disclosing
in the contract that there is a $225 deductible which applies to medical services with limited exceptions. This
cost sharing is a contractual obligation that had not been met at the time the office visit was received on June
14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit you had
with a family medicine doctor on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that orthotics is medically necessary for the way you
walk. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70481) provided on March 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code and is not separately payable.
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 70481 has a bundled relationship with code 70450 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70481) provided on March 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy provided on June 1, 2020 by an out-of-network provider.

You asked the Plan to pay for colonoscopy (45385, 45380). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization as required.

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 colonoscopy provided on June 1, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment (E1390, E0431) provided April 16, 2021.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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% coinsurance for durable medical equipment and related supplies. You have been asked to pay a total cost share of $19.87 for the oxygen equipment ($99.33 Medicare-allowed amount x 20% coinsurance). the oxygen equipment falls within the durable medical equipment and related 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 waive the coinsurance for the oxygen equipment (E1390, E0431) provided April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that one of your legs is shorter than the other and
you have trouble standing for long periods of time. The Plan denied your request. The Plan says this item is not
a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided.