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

We decided that the Plan does not have to pre-approve tubal ligation reversal.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that neither Medicare nor your Medicare Advantage health plan covers this service.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Medicare does not pay for fertility treatment including tubal ligation reversal. There is no medical reason to think that this procedure would treat your symptoms of pelvic pain, dysmenorrhea and heavy menstrual bleeding. There are other types of surgeries and medications for that. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve tubal ligation reversal.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425), and the emergency transport (A0427) provided on October 14, 2020.

You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

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 emergency ambulance is not medically necessary. Our physician reviewer found that other means of transport (taxi, private car, wheelchair van, etc.) would not have endangered the enrollee's health in this case. The reviewer found that a prudent layperson would not believe that without immediate medical attention there would be serious jeopardy to the enrollee's health in this case. Therefore, the reviewer found that the emergency ambulance was not medically necessary.

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 not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425), and the emergency transport (A0427) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the nitric oxide provided on March 11, 2020, the office visit provided on March 18, 2020 and the office visit, nitric oxide, and the ethanolamine oleate injection provided on May 6, 2020.

You asked the Plan to reduce the coinsurance for the nitric oxide, office visits and ethanolamine oleate injection. You say that you did not receive payments equaling half of the charges that had previously been allowed on other claims. You say that the checks should be reissued to reflect half of each charge. The Plan denied your request. The Plan says the coinsurance 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 50% of the total cost for Medicare-covered, out-of-network primary care physician services and physician specialist services and 50% of the total cost for other Medicare Part B drugs from an out-of-network provider. You have been asked to pay $51.15 for the nitric oxide, office visits and ethanolamine oleate injection.

Date of Service
Service
Allowed Amount
Coinsurance
Plan Paid
Member Liability

March 11, 2020
Nitric Oxide
$20.32
50%
$10.16
$10.16

March 18, 2020
Office Visit
$23.57
50%
$11.78
$11.79

May 6, 2020
Office Visit
$23.57
50%
$11.78
$11.79

May 6, 2020
Nitric Oxide
$20.32
50%
$7.25
$7.25

May 6, 2020
Ethanolamine Oleate Injection
$14.50
50%
$10.16
$10.16

TOTAL:
$51.15

The nitric oxide and office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ethanolamine oleate injection falls within the "Medicare Part B prescription drugs" benefit category. The records show the Plan reimbursed you 50% of the allowed amount for each service.

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 reduce the coinsurance for the nitric oxide provided on March 11, 2020, the office visit provided on March 18, 2020 and the office visit, nitric oxide, and the ethanolamine oleate injection provided on May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 9, 2020.
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. 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 21461 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on November 10, 2020, by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 psychotherapy services (90832) provided on November 10, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator rendered on October 19, 2020.

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 Medicare reimburses oxygen equipment for rental only. 

We looked at the file and Medicare rules. The file shows that the oxygen concentrator was purchased and not rented. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator rendered on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on October 12, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis. You say that you believe the treating provider is in-network, and this service should be covered. The Plan denied your request. The Plan says services are only covered for in-network dentists. The Plan also says that the treating dentist is not in-network.
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 prophylaxis provided on October 12, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.

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. 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 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). 

We find that CPT code 88341 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron (Aloxi).
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says anti-emetic drugs can only be approved if the chemotherapy drug is approved.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found as the enrollee has not
responded to Bendamustine, it cannot be approved. As Bendamustine remain denied, an anti-emetic like
Palonosetron also cannot be approved.
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 drug. Therefore, we decided that the Plan does not have to pre-approve
Palonosetron (Aloxi).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on October 6, 2020.

You asked the Plan to pay for a neuromuscular stimulator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a neuromuscular stimulator have not been met.

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 proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery does not identify the item or items delivered. 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 a neuromuscular stimulator (E0745) provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerebral perfusion analysis provided on November 27,
2020.
You asked the Plan to pay for cerebral perfusion analysis using computed tomography with contrast
administration, including post-processing of parametric maps with determination of cerebral blood flow,
cerebral blood volume, and mean transit time (0042T). You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the enrollee received the services in the facility during inpatient
hospitalization.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Payment for this service would be included in the Part A DRG payment to the facility. Payment for this service
is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for the
cerebral perfusion analysis provided on November 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on August 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider

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 the psychotherapy services (90832) provided on August 5, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections of ranizumab (a Medicare Part B drug) provided from November 4, 2020, to January 27, 2021.
You asked the Plan to waive the coinsurance for Part B drugs. You say that you are on a limited income and cannot afford these charges. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are correct.
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 20% coinsurance for Medicare Part B prescription drugs. The allowed amounts of these drugs total $6,362.83, resulting in a coinsurance amount of $1,272.57.
You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B Prescription Drugs 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 coinsurance for injections of ranizumab (a Medicare Part B drug) provided from November 4, 2020, to January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on November 18, 2020.

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. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC. The rules say that codes with a PC/TC indicator of 3 are TC only codes. 

We looked at the file and Medicare rules. The file shows that procedure codes 72220 (sacrum and coccyx x-ray), 73502-LT (hip x-ray), and 73502-RT were not billed with modifier -26 to allow for separate PC payment. Codes R0070 (transportation of portable x-ray equipment) and Q0092 (set-up of portable x-ray equipment) have a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the imaging services rendered on November 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent hospital care (99233) provided on December 31, 2020.

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because the services rendered were emergency services. The Plan denied your request. The Plan says that payment for the billed service has already been considered.

The Plan must follow Medicare rules. Medicare rules say that subsequent Hospital Care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

We find that CPT code 99233 is supported in the medical record. Specifically, the record indicates that this CPT code was paid to a physician of a different specialty than this billing physician. The record does not include any evidence that CPT code 99233 has been paid to the same physician or a physician of the same specialty in the same group on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have been met. Therefore, we decided that the Plan has to pay for the subsequent hospital care (99233) provided on December 31, 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: 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
September 20, 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
September 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS emergency ambulance service (A0427) and ground mileage (A0425) provided October 15, 2020.
You asked the Plan to pay for the ambulance service. You say that please see attached ambulance report to show medical necessity. The Plan denied your request. The Plan says the clinical information provided does not support medical necessity for 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was stable and had no signs or symptoms suggestive of a severe acute condition that would be considered an emergency or in need for immediate care. Other means of transport were not contraindicated such as a stretcher van or a wheelchair van as she could sit without assistance. The enrollee did not need immediate treatment or expertise during transport which could have waited until arrival to the ED. Therefore, this request for ambulance transport on 10/15/2020 will be considered not medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ALS emergency ambulance service (A0427) and ground mileage (A0425) provided October 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of daily living with minimal supervision. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmological examination provided on
December 30, 2020.
You asked the Plan to pay for the ophthalmological examination. The Plan denied your request. The Plan says the documentation submitted did not include documentation that ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation was performed; therefore, the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the ophthalmological examination have not been met. Therefore, we decided that the Plan does not have to pay for an ophthalmological examination provided on December 30, 2020.