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

We decided that the Plan has to pay for the photopheresis services provided on January 23, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the records do not document the progress made or the anticipated length of treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 pay for the services provided. Our physician reviewer found that the enrollee has been diagnosed with Castleman's disease and bronchiolitis obliterans. He has been receiving photopheresis since 2018 with response. The records show that the treatment is indicated for the enrollee's condition. The provided treatment was medically reasonable and 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 services provided have been met. Therefore, we decided that the Plan has to pay for the photopheresis services provided on January 23, 2021.
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 forevaluation and management services (99358, 99359) provided on January 25, 2021 by an out of network (OON) provider.You asked the Plan to pay forvaluation and management services. You say that these services were medically necessary and billed correctly.The Plan denied your request. The Plan says these 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 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 forevaluation and management services (99358, 99359) provided on January 25, 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 the domiciliary or rest home visit for the evaluation and
management of an established patient (99334) rendered by the OON provider on February 6, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established
patient (99334) rendered by the OON provider on February 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services (A0422, A0428, A0425) provided on January 20, 2021.
You asked the Plan to pay for the ambulance transportation services. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says ambulance services and supplies cannot be billed or paid separately as they are included in the base payment for ambulance services. The ambulance services were also provided before the enrollee was discharged from the hospital. Therefore, they were still an inpatient at the time of services and the ambulance transportation is included in the inpatient services payment.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Medicare states that all items and non-physician services, including transportation, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. Medicare rules also state that ambulance supplies are no longer paid separately for ambulance services.
We find that CPT code A0422 is not supported in the record. Specifically, ambulance supplies are not separately payable. Per the Ambulance Fee Schedule, payment for these supplies is included in the base payment for the ambulance services.
We also find that the ambulance transportation services (A0428, A0425) are not supported in the record. Documentation shows that the enrollee was discharged from inpatient hospital status after the transportation was provided on January 20, 2021. Therefore, these services are not separately payable and should be billed through the hospital under arrangements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services (A0422, A0428, A0425) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out of network (OON) provider on January 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) rendered by the out of network (OON) provider on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted procedure, nervous system) (64999) provided October 5, 2020.
You asked the Plan to pay for the unlisted services. You say that the claim was denied as a duplicate. Since the claim is not an exact duplicate you have attached the complete medical records to review the claim. The Plan denied your request. The Plan says unlisted code submitted without description. Provider will need to resubmit with a description for reconsideration. A corrected claim is needed by the IPA in order to review and process the claim. 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 64999 is unlisted procedure, nervous system. We find that CPT code 64999 is not supported in the medical record. Specifically, CPT 64999 is not a listed code. A corrected claim is needed in order to process this claim for payment. Based on this information, we decided that Medicare rules for coverage of the unlisted services have not been met. Therefore, we decided that the Plan does not have to pay for unlisted procedure, nervous system) (64999) provided October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis.
You asked the Plan to pre-approve the MyoPro orthosis. You say that this is a medically necessary item which will help the enrollee use their arm. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the enrollee's condition.
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 MyoPro orthosis. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation by the ordering physician does not support that the requested orthotic device is an accepted standard of medical practice that meets but does not exceed the enrollee's medical need and does not indicate that the device is at least as beneficial as existing and available medically appropriate alternatives. Therefore, this request for MyPro will be considered not medically necessary due to a lack of sufficient supportive information provided. 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan
does not have to pre-approve a MyoPro Motion G orthosis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiologic examination, chest; single view (71045), the transportation of portable x-ray equipment (R0075), and the set-up of portable x-ray equipment (Q0092) rendered by the OONprovider on December 31, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in thiscase 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 forthe radiologic examination, chest; single view (71045), the transportation of portable x-ray equipment (R0075), and the set-up of portable x-ray equipment (Q0092) rendered by the OON provider on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pulp vitality tests (D0460), intraoral -periapical first radiographic image (D0220, limited oral evaluation -problem focused (D0140), the intraoral -periapical each additional radiographicimage (D0230), and the endodontic therapy, molar tooth (excluding final restoration) (D3330) received February 9, and February 25, 2021.You asked the Plan to pay forthe dental services. You say that you were not informed that you did not have supplemental coverage.The Plan denied your request. The Plan says you had supplemental coverage on these dates of service, however the requested services are either excluded, or have frequency limitations which were 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 requested itemsor services are not among those covered under this benefit or are in excess of what is covered under this benefit. The Plan does not provide coverage for limited oral evaluation -problem focused (D0140), pulp vitality tests (D0460), or endodontic therapy, molar tooth (excluding final restoration) (D3330).The Plan provides coverage for intraoral -periapical first radiographic image (D0220), and intraoral -periapical each additional radiographic image (D0230), with frequency limitations. Your benefit is limited to one intraoral x-ray procedure per calendar year.The Plan paid for one intraoral x-ray procedure (D0220) on February 9, 2021. Therefore, the procedures received February 9, 2021 (D0230) and February 25, 2021 (D0220) exceed your benefit's frequency limitation. Based on this information, the Plan has provided coverage in accordance with the Plan contract. Therefore, we decided that the Plan does not have to pay forthe pulp vitality tests (D0460), intraoral -periapical first radiographic image (D0220, limited oral evaluation -problem focused (D0140), the intraoral -periapical each additional radiographic image (D0230), and the endodontic therapy, molar tooth (excluding final restoration) (D3330) received February 9, and February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extractions (D7140 x 6), the complete upper denture (D5110), and the immediate lower denture (D5140) provided from February 26, 2021, to March 5, 2021.You asked the Plan to pay forthe dental services. You say that you thought that you had dental insurance. You say that you ended up having to get a loan to pay out of pocket for these services. You also say that you should be entitled to some payment.The Plan denied your request. The Plan says extractions are not listed as covered services. The Plan says that dentures are not listed as covered either. The Plan alsosays that there is no record that you contacted the Plan prior to the date of service to verify 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 forthe extractions (D7140 x 6), the complete upper denture (D5110), and the immediate lower denture (D5140) provided from February 26, 2021, to March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement services provided on February 1, 2021.
You asked the Plan to pay for the debridement services. You say that the medical records provided support that payment is due for the services billed. The Plan denied your request. The Plan says the code in dispute exceeds the allowable UOS of 1 for the same date of service. The Plan says that the Medicare rules for payment of this claim have not been met.
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 11042 has an MUE of 1 unit, and an MAI 2. This means that there can never can more than one unit of this code be billed for the same date of service. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the debridement services have not been met. Therefore, we decided that the Plan does not have to pay for debridement services provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction services provided on March 11, 2021.You asked the Plan to pay forthe refraction services. You say that you cannot pay the whole bill.The Plan denied your request. The Plan says the claim processed correctly.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services.These services are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay forthe eye refraction services provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), the prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes, (99359), and the telephone evaluation and management service (99443) rendered by the out of network (OON) provider on January 29, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan 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 prolonged evaluation and management service before and/or after direct patient care; first hour (99358), the prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes, (99359), and the telephone evaluation and management service (99443) rendered by the out of network (OON) provider on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Genicular Radiofrequency Ablation procedure (64624).
You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental and is not covered.
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 ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation indicating that the enrollee is not a surgical candidate, or that other treatments would be ineffective for the enrollee's knee.
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 ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Genicular Radiofrequency Ablation procedure (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the Hyaluronan or derivative, gel-one medication, for intra-articular injection, per dose (J7326 x 2) and the office visit (99213) provided on
February 27, 2020.
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 $50 copayment for a specialist office visit. Additionally, you must pay a 20% coinsurance for Medicare Part B drugs administered by a provider. You have been asked to pay $578 which includes the Plan allowed amount of $2,640 x 20% coinsurance=$528 for the Medicare Part B drug injections provided and a $50 copayment for the specialist office visit. 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 adjust the cost share for the Hyaluronan or derivative, gel-one medication, for intra-articular injection, per dose (J7326 x 2) and the office visit (99213) provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic hearing exam provided on October2, 2020.You asked the Plan to waive the copayment fora hearing exam. You say that the service should be covered as a routine exam.The Plan denied your request. The Plan says the cost share 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 $35 copayment for hearing services. You have been asked to pay a$35 copayment for a hearing exam. This service falls within the hearing services benefit category. You received a diagnostic hearing exam by an audiologist, this is not a routine hearing exam. 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 fora diagnostic hearing exam provided on October 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal injection services (62323) provided on June 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the spinal injection services. You say that you were not aware you needed to obtain prior authorization. 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 spinal injection services (62323) provided on June 8, 2020 by an out of network (OON) provider.