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

We decided that the Plan does not have to pre-approveepidural injections.You asked the Plan to pre-approvethe requested services. You say that you have been suffering from pain for twelveyears.The Plan denied your request. The Plan says the requested injection is considered experimental.The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered under certain medical indications. 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 requested services. Our physician reviewer found thatthere is no documented evidence on physical exam,or from recent imaging studies,that indicate any specific lumbosacral nerve root etiology for this enrollee's pain. There is no documentation that you havemet requirements of failure of fourweeks of conservative treatment for your worsening pain. You also donot meet criteria for the caudal epidural steroid injection,as contraindications to these injections include cancer and infection, which have not been ruled out first. Therefore, the requested injection is not medically reasonable or necessary at this time.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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approveepidural injections
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of
intraoral x-rays, preventive procedure, and prophylaxis provided on October 13, 2020, by an out-of-network
(OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays,
preventive procedure, and prophylaxis. You say that this dentist was given to you by the Plan. The Plan denied
your request. The Plan says these services were rendered by a non-participating provider. The Plan also says
that the calls on file were verified, and you did not contact the Plan for assistance in finding a provider.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation, complete series of intraoral x-rays, preventive procedure, and prophylaxis
provided on October 13, 2020, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services rendered on
September 3, 2020.
You asked the Plan to waive the copayment for these services. You say that you were told that you should
appeal the copayment. 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). Your contract with the Plan clearly says that you must pay a $30
copayment per day for Medicare-covered physical therapy services.
Review of the file shows that you received physical therapy services on September 3, 2020. You have been
asked to pay a $30 copayment for these services. These services fall within the Medicare-covered physical
therapy 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 physical therapy
services rendered on September 3, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe ambulance services (A0425, A0426) provided on July 25, 2020.You asked the Plan to pay forthe ambulance services. You say that the ambulance transport was medically necessary.The Plan denied your request. The Plan says that the information provided did not support the medical necessity of ambulance transport.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 transport was medically reasonable and necessary. Our physician reviewer found the patient had a number of complaints such as abdominal pain and nausea. In addition, the patient also admitted to alcohol and drug use. Given the impaired nature potentially of this patient, the information available supports the medical necessity of ambulance 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 been met.Therefore, we decided that the Plan has to pay forthe ambulance services (A0425, A0426) provided on July 25, 2020.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 forthe comprehensive oral evaluation, prophylaxis, panoramic x-ray, four localized deliveries of antimicrobial agents, and periodontal maintenance provided from September 9, 2019, to July 1, 2020.You asked the Plan to pay forthe comprehensive oral evaluation, prophylaxis, panoramic x-ray, four localized deliveries of antimicrobial agents, and periodontal maintenance. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the original claim was received outside the timely filing guideline because aclaim for services must be received within 12 months of the date services were rendered. The Plan also says that the panoramic x-ray, localized deliveries of antimicrobial agents, and periodontal maintenance are not covered benefits.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. Medicare generally does not cover dental services. However, the Plan offers a dental benefitthat exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The record shows that a claim for the comprehensive oral evaluation and prophylaxis was not filed until September 20, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Although the Plan offers a dental benefit in excess of Medicare coverage, the panoramic x-ray, localized deliveries of antimicrobial agents, and periodontal maintenance are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, prophylaxis, panoramic x-ray, four localized deliveries of antimicrobial agents, and periodontal maintenance provided from September 9, 2019, to July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine eye exam provided on August 20, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe routine eye exam. You say that you are unable to go to the Plan's routine vision vendor.The Plan denied your request. The Plan says you must receive your care from the Plan's routine vision vendor.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 they are provided by the Plan's routine vision vendor.We looked at the file and the Plan's rules. The file indicates that you received these services from an out-of-network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been met.Therefore, we decided that the Plan does not have to pay forthe routine eye exam provided on August 20, 2020, byan out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe magnetic resonance imaging (MRI) of the brain provided on October 1, 2020.You asked the Plan to waive the copayment forthe MRI of the brain. You say that you would like this claim reprocessed and copayment waived.The Plan denied your request. The Plan says the copayment processed correctly for 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 $150 copayment for advanced imaging services. You have been asked to pay a $150 copayment for theMRI of the brain. The service provided falls within the advanced imaging 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 forthe magnetic resonance imaging (MRI) of the brain provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periapical x-ray (D0220) the additional periapical x-ray (D0230) provided on September 17, 2020.You asked the Plan to pay forthe periapical x-rays. You say that the provider is submitting fraudulent charges. You say that you did not receive a comprehensive exam on September 17, 2020. You say that you did not receive any services on September 18, 2020. You also say that the Plan should not pay for any of the services as they did not happen.The Plan denied your request. The Plan says oneperiapical x-ray is covered per calendar year. The Plan says that the frequency limit for this services has been exceeded.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 frequency limit of oneperiapical x-ray per calendar year has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on May 21, 2020.Therefore, we decided that the Plan does not have to pay forthe periapical x-ray (D0220) the additional periapical x-ray (D0230) provided on September 17, 2020.Your complaint about the services which the plan paid for 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEVENITY.You asked the Plan to pre-approveEVENITY (J3111). You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to oral bisphosphonate and either zoledronic acid or Prolia.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 EVENITY (J3111). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records provided the patient has not triedand failed the required drugs. Based on the medical records provided there is no indication that the plan's required drugswould likely be less effective and/or likely have adverse effects for the patient. The patient reportedly has stage III chronic kidney disease, records indicate her glomerular filtration rate is 50 mL/minute; this is not a contraindication to zoledronic acid or Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of EVENITY (J3111) have not been met.Therefore, we decided that the Plan does not have to pre-approveEVENITY.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on July 21, 2020.
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
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 medical services provided to the enrollee by an out-of-network
provider on July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the diagnostic tests provided.

You asked the Plan to waive the co payment for the ophthalmic diagnostics. You say that there shouldn't be a co payment for the tests.The Plan denied your request. The Plan says you were charged this co payment correctly.

The rules say a plan must disclose to its enrollee in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co payment for Outpatient Diagnostic Tests, separate office visit copay applies. 

You have been asked to pay a $46.06 co payment for the ophthalmic diagnostics. The ophthalmic diagnostic testing falls within the Outpatient Diagnostic Tests benefit category. The allowed amount was less than your co payment which is why the co payment 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 co payment for the diagnostic tests provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acupuncture treatment (97810, 97811) provided on June 18, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says thisservice is not payable as it was provided by a licensed acupuncturist, not a physician.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coveragebeyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture treatmenthave not been met. Specifically, the acupuncture was not provided by a physician licensed to perform the service.Therefore, we decided that the Plan does not have to pay forthe acupuncture treatment (97810, 97811) provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on October
12, 2020.
You asked the Plan to waive the copayment for these services. You say that the copayment should be less than
a regular doctor visit. 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). Your contract with the Plan clearly says that you must pay a $40
copayment for visits to specialists.
Review of the file shows that you received specialist services on October 12, 2020. You have been asked to pay
a $40 copayment for these services. These services fall within the visits to specialists 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 specialist services rendered on October 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service coded A0427 and the specialty care
transport coded A0434 provided on February 4, 2020.
You asked the Plan to pay for the ambulance service and the specialty care transport. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not
supported by the documentation.
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 A0427 is ambulance service, advanced life support,
emergency transport, level 1 (als 1 - emergency). The CPT Code Manual definition of code A0434 is specialty
care transport (sct).
We asked our coding 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 service and the specialty care
transport. Our reviewer says that the documentation does not support that use of these codes billed. Our coding
reviewer found the documentation shows that the provider clearly documents all enrollee care was provided by
them, and the ambulance was driven by a different provider. In situations where the BLS entity provides the
transport of the beneficiary and an ALS entity provides a service that meets the fee schedule definition of an
ALS intervention (e.g., ALS assessment, Paramedic Intercept services, etc.), the BLS supplier may bill
Medicare the ALS rate provided that a written agreement between the BLS and ALS entities exists prior to
submitting the Medicare claim. Providers/suppliers must provide a copy of the agreement or other such
evidence (e.g., signed attestation) as determined by their A/B MAC (A) or (B) upon request. A/B MACs (A)
and (B) must refer any issues that cannot be resolved to the regional office. Medicare does not regulate the
compensation between the BLS entity and the ALS entity. If there is no agreement between the BLS
ambulance supplier and the ALS entity furnishing the service, then only the BLS level of payment may be
made. In this situation, the ALS entity's services are not covered, and the beneficiary is liable for the expense of
the ALS services to the extent that these services are beyond the scope of the BLS level of payment". No
agreement between the ground ambulance service and the ALS provider was included in this review to support
billing HCPCS A0427 and HCPCS A0434.
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 ambulance service and the specialty care transport have not been met.
Therefore, we decided that the Plan does not have to pay for the ambulance service coded A0427 and the
specialty care transport coded A0434 provided on February 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the spine provided on July 29, 2020.
You asked the Plan to waive the copayment for the MRI of the spine. You say that you were unaware how
much this service would cost. The Plan denied your request. The Plan says the copayment processed correctly
for 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 $325
copayment for diagnostic radiology other than computed tomography scan.
You have been asked to pay a $325 copayment for the MRI of the spine. The MRI of the spine falls within the
diagnostic radiology other than computed tomography scan 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 magnetic resonance imaging (MRI) of the spine provided on July 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe EEG provided on September 14, 2020.You asked the Plan to pay forthe EEG. 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 pay for the EEG. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 80-year-old man with a diagnosis of cervical disc disorder at the C5-C6 level with myelopathy, who underwent C5-C6 anterior cervical discectomy and fusion. The value of this EEG, in terms of impact on the management and outcome of this enrollee, has not been adequately demonstrated.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 EEG have not been met.Therefore, we decided that the Plan does not have to pay forthe EEG provided on September 14, 2020