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

We decided that the Plan does not have to pay for the emergency department visit (99284) provided December 24, 2020.
You asked the Plan to pay for the emergency visit. You say that this enrollee went into the emergency room and was seen by the emergency room physician for a medically necessary procedure. Please reprocess this claim and pay this procedure code. The Plan denied your request. The Plan says beneficiaries in custody under a penal authority, services rendered to incarcerated members are not payable.
The Plan must follow Medicare rules. Medicare rules say that Medicare will generally not pay for medical items and services furnished to a beneficiary who is incarcerated or in custody at the time items and services are furnished.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided December 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on March 22, 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 billed incorrectly.

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 testing rendered on March 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 60 trip limit.

You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to dialysis appointments. The Plan denied your request. The Plan says the requested trips exceed the Plan's maximum and are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. The Plan has provided documentation showing that you had used 59 of the 60 routine transports at the time of the appeal. The request for 300 additional trips is beyond the Plan's 60 trip limit. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 60 trip limit.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on January 18, 2021
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided from January 31, 2020, to March 12, 2020.
You asked the Plan to pay for office services. You say that you can find no documentation that says you have to file claims within 1 year. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
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. The record shows that a claim for office services was not filed until March 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for office services provided from January 31, 2020, to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on May 4, 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 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 you received on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99232) provided on February 16, 2021, and February 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not billed with the appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that modifier -24 reports an unrelated evaluation and management service by same physician during a postoperative period. 

We looked at the file and Medicare rules. The services in question were provided during the surgical global period, but were unrelated to the surgical procedure. In this case, modifier -24 is required to indicate that the services were unrelated to the surgical procedure. Modifier -24 was not billed for these services. 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 (99232) provided on February 16, 2021, and February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99443) provided on April 20, 2021.

You asked the Plan to pay for the telephone evaluation and management service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99443 was billed on the same date as another evaluation and management service which was billed by the same billing provider.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99443 is not supported in the record. Specifically, the record indicates that another evaluation and management service was billed on the same date of service by the same billing provider. The billing providers have the same specialty. In this case, onle one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Based on this information, we decided that Medicare rules for coverage of the telephone evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service (99443) provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on April 7, 2021.
You asked the Plan to pay for a teeth cleaning, and bitewing radiographic images. You say that you were not aware that your provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a teeth cleaning, and bitewing radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers
available to provide these services. 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 a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision field assessment tech support 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 procedure is considered experimental and investigational.

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 record indicates that the enrollee has non-exudative age-related macular degeneration. The record submitted does not contain medical records supportive of the requested service. The provided records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's specific clinical condition. The elements of the coverage rules 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 pre-approve vision field assessment tech support for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210) provided on April 1, 2021.

You asked the Plan to pay for extractions. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 this benefit. Therefore, we decided that the Plan does not have to pay for extractions (D7210) provided on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
You asked the Plan to pre-approve the additional trips. You say that the enrollee qualifies for rides to medical visits. The Plan denied your request. The Plan says there are zero trips remaining for 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device rendered on February 5, 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 are not covered.

The Plan must follow Medicare rules. The rules say that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is not covered. 

We looked at the file and Medicare rules. The item at issue is an intermittent limb compression device billed with code E0676. This item is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device rendered on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Based on your current medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic
medical conditions. There are no documented acute rehab nursing needs. Functionally at your level, there is no evidence of need for an intensive therapy program with therapy 3 hours per day when your activity tolerance is low to poor. Your rehab needs can be easily and safely met at a less intense and alternate level of setting such as in an skilled nursing facility. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan identified with code 93925 received on March 27, 2021.

You asked the Plan to pay for the duplex scan. You say that these services were necessary as the doctors were concerned about a blood clot after undergoing a heart ablation. The Plan denied your request. The Plan says the services received were billed incorrectly.

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 93925 is duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study. 

We find that CPT code 93925 is not supported in the medical record. Specifically, this code was billed with a modifier indicating a unilateral procedure was performed. This code represents a bilateral service. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan identified with code 93925 received on March 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back orthosis provided on October 22, 2020.
You asked the Plan to pay for the back orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records do not support the indications for a spinal orthosis.
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 or relevant medical records which support medical necessity for the supplies provided in this case. The physician order date is the day before the office visit and the medical records do not mention the need or recommendation for the orthosis. 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 back orthosis provided on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) scan rendered on April 20, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The file shows that the services were billed with POS code 22 for an outpatient hospital facility; however, the enrollee was under inpatient status for the date of service at issue.

Therefore, we decided that the Plan does not have to pay for the computed tomography angiography (CTA) scan rendered on April 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 8, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you feel that the skilled nursing facility is the reason you needed to be transferred to the emergency room and you should not owe the copayment. 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 $225 copayment for ambulance services. 

You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for denture repair/replace broken tooth (D5640) provided on April 7, 2021.

You asked the Plan to pay an additional amount for denture repair/replace broken tooth. You say that you want the Plan to pay an additional amount for the service. The Plan denied your request. The Plan says the Plan paid their 50% portion for the service and you are responsible for the remainder.

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 denture repair/replace broken tooth have not been met. Specifically, the Plan paid their 50% portion for the service and you are responsible for the remaining 50% of the allowed charge. Therefore, we decided that the Plan does not have to pay an additional amount for denture repair/replace broken tooth (D5640) provided on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nuclear myocardial perfusion imaging (78452).
You asked the Plan to pre-approve the diagnostic service. You say that if this is not approved, you can have the
enrollee do a calcium scoring computed tomography (CT) scan to get a reading of calcium plaque. The Plan
denied your request. The Plan says the medical records do not support that the medical necessity criteria has
been met.
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 diagnostic service. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee has a history of hypertension and
hypercholesterolemia. The record indicates that the enrollee has palpitations that decrease when caffeine is
limited. The enrollee has no other cardiac related symptoms. The electrocardiogram has no abnormalities. No
other cardiac testing has been performed. The provided record supports that the requested test is screening in
nature. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan
does not have to pre-approve nuclear myocardial perfusion imaging (78452).