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

We decided that the Plan does not have to pay for Feraheme (Q0138) for the enrollee.
You asked the Plan to pay for the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the provider should be billing Q0139 - end stage renal disease (ESRD) use which would then be covered per the CMS dialysis bundle.
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 Healthcare Common Procedure Coding System (HCPCS) code Q0138 is "Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use)." We find that the use of HCPCS code Q0138 is not supported. The enrollee has end-stage renal disease (ESRD). Q0138 specifically is defined as for non-ESRD use. The records show that the enrollee is currently on dialysis, so the current code to use in this case would be Q0139, the definition of which is "Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis)." Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pay for Feraheme (Q0138) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out--of-network provider on July 29, 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 services provided by an out--of-network provider on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on December 4, 2020.
You asked the Plan to pay for the shingle vaccine. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingle vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the shingle vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on December 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network physical therapy referral for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is not in the primary care physician's 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 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 an out-of-network physical therapy referral for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the artificial eye provided on October 7, 2020.
You asked the Plan to pay for the artificial eye represented by codes V2624, V2627, V2628, V2629. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order therefore the billed services cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. There is no physician order in the file. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the artificial eye provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered services, custodial care (A9270) provided October 29, 2020 to January 1, 2021.
You asked the Plan to pay for the custodial care services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says custodial care services is not covered by Medicare or the Plan under any condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care services have not been met. Therefore, we decided that the Plan does not have to pay for non-covered services, custodial care (A9270) provided October 29, 2020 to January 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88300) provided to the enrollee on March 8, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the concepts of professional and technical components do not apply to procedure codes with a "0" indicator, as these services cannot be split into professional and technical components.
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 88300 is "Surgical Pathology, gross examination only." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the record indicates that the enrollee received CPT 88300 services. The procedure code has an indicator of 0. The professional and technical components cannot be separately billed. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88300) provided to the enrollee on March 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on April 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 70450 is part of an edit pair with procedure code 70496. Procedure code 70496 is a column one code, and procedure code 70450 is a column two code. Procedure code 70496 has been paid on this date of service, which means that procedure code 70450 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment panels (CPT code(s): 81238, 81286, 81439) provided to the enrollee on September 16, 2020.
You asked the Plan to pay for the laboratory testing. You say that the treatment is medically necessary to treat the enrollee based on the enrollee's medical conditions. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The enrollee had cardiovascular risk assessment testing on September 16, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment panels (CPT code(s): 81238, 81286, 81439) provided to the enrollee on September 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need extra days to finish the services you are receiving at the moment. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from March 7,
2021, to March 8, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you were admitted overnight so
should not be responsible for the emergency room charges. 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 $120
copayment for emergency care. If you are admitted to the same hospital within 24 hours for the same condition,
you pay $0 for the emergency room visit.
You received emergency care on March 7, 2021, to March 8, 2021. The record does not indicate that you were
admitted inpatient. Therefore, you are responsible to pay the $120 copayment. Please note, the emergency
room copayment is less than the inpatient hospital copayment and is in your financial favor.
You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency
care 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 emergency care provided from
March 7, 2021, to March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on September 10, 2020.
You asked the Plan to pay for the resin-based composite. You say that when one of your team members contacted the Plan on July 15, 2019, they were advised that fillings were covered at the time of the call. The Plan denied your request. The Plan says the enrollee did not have the optional benefit that covers comprehensive dental services for this date of service.
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 enrollee did not have the optional supplemental benefit package that offers coverage for comprehensive dental services on this date of service. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified diagnostic procedure (D0999), replacement of missing or broken denture tooth (D5520), and a denture reline (D5751) provided on March 19, 2021.
You asked the Plan to pay for the dental services. You say that you did not know your dental Plan changed and your provider did not inform you that these services would not be covered. The Plan denied your request. The Plan says these services are not covered by your dental benefits.
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 the supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for an unspecified diagnostic procedure (D0999), replacement of missing or broken denture tooth (D5520), and a denture reline (D5751) provided on March 19, 2021, under the Plan's dental benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an unspecified preventive procedure (D1999) provided on April 1, 2021.
You asked the Plan to pay an additional amount for a periodic oral evaluation, a teeth cleaning, and an unspecified preventive procedure. You say that the services at issue should be covered. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made. An unspecified preventive procedure is not a covered benefit.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and an unspecified preventive procedure have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Additionally, an unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and an unspecified preventive procedure (D1999) provided on April 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99347) provided on October 25, 2019.
You asked the Plan to pay for the home visit. You say that the services provided were medically necessary. The
Plan denied your request. The Plan says the enrollee received this home visit by a social worker. The Plan also
says that the records do not indicate that a physician was present at the time of the home visit.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician
unless the physician was actually present in the beneficiary's home.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the
home visit for the evaluation and management of an established patient (99347) provided on October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on November 12, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies all cardiovascular risk assessment testing, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The hereditary testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on November 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem ER tab 12.5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit, as it is self-administered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem ER tab 12.5mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence panel provided on January 27, 2021.
You asked the Plan to pay for the testing services. You say that the test is a medically necessary benefit. The Plan denied your request. The Plan says the billed code is non-covered.
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. The test is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence panel provided on January 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you are comfortable with this provider. The
Plan denied your request. The Plan says there are in-network providers available.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. We found no exception that would require the Plan to preapprove
these OON services. Therefore, we decided that the Plan does not have to pre-approve outpatient
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider from March 5, 2021 through March 18, 2021.
You asked the Plan to pay for physical therapy. You say that medical records warrant the medical necessity of the service billed and the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 physical therapy provided by an out-of-network provider from March 5, 2021 through March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture, 1 or more needles; with electrical
stimulation, initial 15 minutes (97813 x 4), the acupuncture, 1 or more needles; with electrical stimulation,
additional 15 minutes (97814 x 4), and the infrared therapy (97026) x 4) provided from August 31, 2020, to
October 2, 2020.
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan
denied your request. The Plan says acupuncture services are only covered when they are performed or
supervised by any physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist
(CNS).
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 coverage beyond 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 services have not been met. Specifically, the record does not show that these services were
rendered by a physician. There is no indication that the provider was supervised by a physician, PA or
NP/CNS. Additionally, infrared therapy is not a Medicare covered benefit. Therefore, we decided that the Plan
does not have to pay for the acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes
(97813 x 4), the acupuncture, 1 or more needles; with electrical stimulation, additional 15 minutes (97814 x 4),
and the infrared therapy (97026) x 4) provided from August 31, 2020, to October 2, 2020.