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

We decided that the Plan has to waive the coinsurance for the office visit (99204), therapeutic exercises (97110), manual therapy (97140), neuromuscular reeducation (97112), therapeutic activities (97530), physical therapy evaluation (97162), and the electrical stimulation (G0283) provided from March 11, 2021, through March 30, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the coinsurance has been applied correctly to the services 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 does not say in clear and accurate terms how much you should expect to pay for a physician specialist visit and physical therapy services. We looked at your contract with the Plan. The Plan contract does not clearly say how much enrollees must pay for a physician specialist visit and physical therapy services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the office visit (99204), therapeutic exercises (97110), manual therapy (97140), neuromuscular reeducation (97112), therapeutic activities (97530), physical therapy evaluation (97162), and the electrical stimulation (G0283) provided from March 11, 2021, through March 30, 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 pay for the stomach lesion repair (43840) gastrojejunostomy revision
(43860) provided on December 18, 2020.
You asked the Plan to pay for the stomach surgery. You say that you would like reconsideration because these
services were billed with the appropriate diagnosis code. The Plan denied your request. The Plan says these
services were not billed with an appropriate primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT codes 43860 and 43840 are not supported in the medical record. Specifically, this claim has
been billed with diagnosis code T81.12XA. This diagnosis code includes a code first note, indicating that the
etiology should be sequenced first. This code is not an appropriate primary diagnosis code. Based on this
information, we decided that Medicare rules for coverage of the stomach surgery have not been met. Therefore,
we decided that the Plan does not have to pay for the stomach lesion repair (43840) gastrojejunostomy revision
(43860) provided on December 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport provided on December 1, 2020.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the
ambulance transport was medically necessary. The Plan denied your request. The Plan says ambulance
transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered
benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 ambulance service, basic life support, nonemergency
transport. Our reviewer says that the ambulance service was not medically reasonable and
necessary. Our physician reviewer found that the enrollee is a 78-year-old woman who was transported by
ambulance to an infusion center for treatment of a malignant (primary) neoplasm, unspecified.
The enrollee's vital signs were normal. The enrollee was transferred onto the gurney via sheet drag x3 without
incident due to general weakness. The enrollee "required no medical treatment during transport and was
compliant." The documentation does not support that another means of transport was contraindicated for this
enrollee on December 1, 2020. The documentation does not support that the enrollee needed the expertise,
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe
transport on December 1, 2020. The documentation does not support that the ambulance transport on December
1, 2020 was medically reasonable and necessary for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, nonemergency
transport provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274), and periodontal maintenance (D4910) provided March 23, 2021.
You asked the Plan to pay for the periodic oral exam, intraoral x-rays, bitewing x-rays and periodontal maintenance. You say that you did not know when you made an appointment with your long-time dentist that the services would not be covered. The Plan denied your request. The Plan says these services are not covered because the provider has opted out of Medicare.
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 periodic oral exam, intraoral x-rays, bitewing x-rays and periodontal maintenance when you see a licensed dental provider who accepts Medicare patients in the United states and has not opted out of Original Medicare. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who had opted out of the Medicare program from April 24, 2015, through April 24, 2021. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, intraoral x-rays, bitewing x-rays and periodontal maintenance have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274), and periodontal maintenance (D4910) provided March 23, 2021.
Your complaint about the Plan previously providing coverage for services from this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 3, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from an out-of-network provider on April 21, 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 service 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 you received from an out-of-network provider on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical tooth extractions (D7210), alveoloplasty (D7310) and lower jaw tissue conditioning (D5851) provided on April 14, 2021, and April 21, 2021.
You asked the Plan to pay for the dental services. You say that you switched dental plans in 2020 because you believed you would have more coverage for the services you needed. The Plan denied your request. The Plan says these services are not covered by your dental plan which became effective on April 1, 2021. Your dental coverage changed because you switched to a new medical plan.
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. Therefore, we decided that the Plan does not have to pay for the surgical tooth extractions (D7210), alveoloplasty (D7310) and lower jaw tissue conditioning (D5851) provided on April 14, 2021, and April 21, 2021.
Your complaint about a potential miscommunication regarding your change in coverage plans is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on June 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that you were not able to obtain authorization. The Plan denied your request. The Plan says authorization is required for out-of-network 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 an office visit (99214) provided on June 8, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on August 29, 2020.
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for ambulance services provided on August 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on February 11, 2021.
You asked the Plan to waive the copayment for these services. You say that the enrollee had to endure pain due to misjudgment of the doctor. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for surgery services in a specialist's office.
Review of the file shows that the enrollee received outpatient surgical services in a specialist's office on February 11, 2021. The enrollee has been asked to pay a $25 copayment for these services. These services fall within the surgery services in a specialist's office 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. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on February 11, 2021.
Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on March 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on March 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office services. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 office services provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain rendered on April 9, 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 70450 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 70450 (CT of the head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain rendered on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 22, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with medical records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this provider is
out-of-network with the Plan and authorization was not 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 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 an office visit provided on January 22, 2021 by an
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on November 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 99285 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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function." 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 services. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that the documentation supports an expanded problem focused history, detailed exam, and medical decision making of high complexity. Per CPT guidelines for emergency room visits, the documentation must meet or exceed 3 key components when reporting level of service for evaluation and management services. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99285) provided on November 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower esophagogastroduodenoscopy (EGD) and colonoscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the gastroesophageal reflux disease (GERD) is well-controlled on current medications.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has medication controlled gastroesophageal reflux disease and is asymptomatic. This condition is not a covered indication for esophagogastroduodenoscopy. Additionally, the record further indicates that the enrollee has a personal history of benign colonic polyp that was removed on 2016. The record indicates that the enrollee has a family history of colonic polyps and paternal family members with colon cancer. This condition is not a covered condition for colonoscopy. The elements of the coverage criteria are not satisfied for either requested procedure. 
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve upper and lower esophagogastroduodenoscopy (EGD) and colonoscopy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trabeculoplasty by laser surgery for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the accepted indications for trabeculoplasty include open-angle glaucoma not adequately controlled on maximal tolerated medical therapy, and open-angle glaucoma in cases in which compliance with medical therapy is less than optimal due to practical, social, or economic reasons or if the medical adverse effect profile is considered unfavorable for the patient. The enrollee does not have an accepted indication for trabeculoplasty. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve trabeculoplasty by laser surgery for the enrollee.