Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an out-of-network right carotid endarterectomy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary.The Plan denied your request. The Plan says a second opinion with an in-network vascular surgeon has been approved.

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 referral for an out-of-network right carotid endarterectomy.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe interpretation of the diagnostic mammography provided on June 10, 2020, billed with one unit of 77066-26.You asked the Plan to pay forthe mammography interpretation. You say that the records support this claim.The Plan denied your request. The Plan says that all codes were paid, aside from 77066 as only one unit may be billed per date of service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a valid denial rationale in this case. The Plan states that this code was denied since two units were billed, and there is an MUE of 1. However, both the claim and the remittance advice clearly show that only one unit of this code was billed. One unit of this code is allowed on a date of service. No alternate rationale was provided, and there are no obvious defects with the claim. As such, we find this denial of payment is unsubstantiated.Therefore, we decided that the Plan has to pay forthe interpretation of the diagnostic mammography provided on June 10, 2020, billed with one unit of 77066-26.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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to to an out-of-network pain management specialist.You asked the Planto pre-approvethe referral. You say that you are having severe pain and need to see a pain management physician.The Plandenied your request. The Plansaysthere are participating providers accepting new patients at this time.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe 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 Plandoes not haveto pre-approvea referral to to an out-of-network pain management specialist.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory and related services coded 36415, 84145, 85025, 87040, 87040, 87086, 81001, and 93005 and U0001 provided on June 12, 2020.You asked the Plan to pay forthe laboratory and related services. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services billed are not 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.We find that CPT codes 36415, 84145, 85025, 87040, 87040, 87086, 81001, and 93005 are not supported in the medical record. Specifically, code 36415 has a status indicator "Q4", which designates packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator "J1," "J2," "S," "T," "V," "Q1," "Q2," or "Q3". Code 84145 has a Status indicator "Q4", which designates packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator "J1," "J2," "S," "T," "V," "Q1," "Q2," or "Q3".Codes 87040, 87040 91, 87086have a status indicator "Q4", which designates packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator "J1," "J2," "S," "T," "V," "Q1," "Q2," or "Q3". Code 81001 has a status indicator of "Q4", which designates packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator "J1," "J2," "S," "T," "V," "Q1," "Q2," or "Q3". Code 93005 has a status indicator of QI, which is not separately payable. Lastly, code U0001 was billed with an incorrect modifier. Based on this information, we decided that Medicare rules for coverage of the laboratory and related services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory and related services coded 36415, 84145, 85025, 87040, 87040, 87086, 81001, and 93005and U0001provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary and should be paid.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 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 medical services provided by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 31, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice election has been revoked or terminated.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a soft retractable queen size mattress.

You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your
request. The Plan says this is a convenience item that does not serve a medical purpose.

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 pre-approve a soft retractable queen size mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventative procedure (D1999) provided on July 7, 2020.You asked the Plan to pay forthe unspecified preventative procedure. You say that you would like this claim processed and approved for payment based on previous experience.The Plan denied your request. The Plan says these services are not covered by the Plan's supplemental coverage.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 forthe unspecified preventative procedure (D1999) provided on July 7, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) provided on April 6, 2020.

You asked the Plan to pay for CGM supplies. You say that the enrollee needed these supplies. The Plan denied your request. The Plan says the criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use at least three daily injections of insulin. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies (K0553) provided on April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that your doctor was not available and you needed to see a doctor for your medication. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that they confirmed with your primary care doctor's office that there is no evidence that you attempted to schedule an appointment with them in the month of July.

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 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 the medical services provided on July 30, 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 continued use of the Optune device and transducer arrays 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 enrollee had progression requiring stereotactic radiation therapy. The enrollee does not use the device 18 hours per day.

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 continued use of the Optune device and transducer arrays for t he enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemodenervation of muscle provided on July 8, 2020.

You asked the Plan to waive the copayment for the chemodenervation of muscle. You say that according to the Plan waiver letter the copayment should be waived. 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 $100 copayment for outpatient surgery. 

You have been asked to pay a $100 copayment for the chemodenervation of muscle. the chemodenervation of muscle falls within the outpatient surgery 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. The Plan's cost share waiver says members will be responsible for their share of the cost of outpatient surgery services. Therefore, we decided that the Plan does not have to waive the copayment for the chemodenervation of muscle provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) provided on March 17, 2020.
You asked the Plan to pay for the dental services. You say that the services qualify for coverage because they were an emergency. You say that no other providers were available due to Covid-19. You also say that it was mandated that all dental offices only treat patients requiring emergency care from March 17, 2020, to March 31, 2020. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for services that are rendered by a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The record shows that you received a consultation for root canal services in February which shows that the root canal was planned and not an emergency. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on March 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee on July 21, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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. 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 forout of network physician services provided to the enrollee on July 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on August 10, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that you feel that the copayment should be waive due to COVID-19.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 radiological diagnostic services. You have been asked to pay the allowed amount of $77.34, which is less than the $110 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This meansthat 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 foran ultrasound provided on August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transforaminal epidural injection provided on August 17, 2020.
You asked the Plan to waive the copayment for the transforaminal epidural injection. You say that you never had a copayment before. 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 outpatient hospital services. You have been asked to pay a $250 copayment for the transforaminal epidural injection. The transforaminal epidural injection falls within the outpatient hospital 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 transforaminal epidural injection provided on August 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 16, 2020 by an out of network (OON) provider.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the provider is not in network.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 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. 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 forthe medical services provided on July 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a wound repair (12001) provided February 25, 2020.
You asked the Plan to pay for the wound repair. You say that the services were medically necessary. The Plan denied your request. The Plan says the units billed exceed the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 12001 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the wound repair have not been met. Therefore, we decided that the Plan does not have to pay for a wound repair (12001) provided February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services that includes a crown and prep work with dental codes D2954 and D2790 provided on May 14, 2020.You asked the Plan to pay forthe dental services with dental codes D2954 and D2790. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the dental services are not covered by Medicare or the Plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, wedecided that the Plan does not have to pay forthe dental services that includes a crown and prep work with dental codes D2954 and D2790 provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0457) provided to the enrollee on July 10, 2020.
You asked the Plan to pay for the back brace. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0457) provided to the enrollee on July 10, 2020.