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

 We decided that the Plan does not have to pre-approve Remicade.  You asked the Plan to pre-approve Remicade. The Plan denied your request. The Plan says there can be no concurrent treatment with other biological drugs.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Remicade. Our physician reviewer found that the enrollee has rheumatoid arthritis with several swollen, painful small joints, as well as unilateral primary osteoarthritis of the left knee. The enrollee has been treated with Actemra, and is currently on Humira, Arava, and prednisone. Remicade is FDA-approved for the treatment of moderate to severe rheumatoid arthritis in combination with methotrexate and can be used as monotherapy. It does not appear that Remicade is to be used as monotherapy. It is not clear from the documentation whether the plan is to use Remicade in combination with methotrexate. It is not clear what the enrollee's treatment regimen is to be. The documentation is insufficient to demonstrate that Remicade is safe and effective and otherwise reasonable and necessary for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have to pre-approve Remicade.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation services provided from August 17, 2021, to August 18, 2021.  You asked the Plan to pay for the services provided. You say that the observation has to be billed separately. The Plan denied your request. The Plan says the claim was processed correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The claim shows that observation code, G0378 was reported for each date of service. If a period of observation spans more than 1 calendar day, all of the hours must be included on a single line and the date of service for that line is the date that observation care begins. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the observation services provided from August 17, 2021, to August 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital services provided from March 1, 2021, to March 11, 2021.  You asked the Plan to pay for the inpatient services. You say that the enrollee was not enrolled in hospice on the dates of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on March 1, 2021. The enrollee's inpatient services began while the enrollee was still enrolled in hospice. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital services provided from March 1, 2021, to March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group two power wheelchair (K0838) and accessories.  You asked the Plan to pre-approve a group two power wheelchair and accessories. You say that the item is medically necessary. The Plan denied your request. The Plan says the requested items does not meet medical necessity criteria.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 a group two power wheelchair and accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is inadequate documentation in the "face to face" telehealth visit note that the patient meets Medicare criteria for the requested group 2 heavy-duty, single power option power wheelchair and accessories.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group two power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group two power wheelchair (K0838) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and related services provided on March 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services provided are not a covered benefit.    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 office visit and related services provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services (S9330) provided from February 18, 2021, to February 27, 2021.  You asked the Plan to pay for code S9330. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, CPT code S9330 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9330) provided from February 18, 2021, to February 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 10, 2021, to September 16, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel that you are being charged extra for a private room, and you had no control over which room you were in. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $343 per day for days 1-4 and $0 per day for days 5-90 for each inpatient stay.   The file shows that you were in the hospital from September 10, 2021, to September 16, 2021. Therefore, you have been asked to pay $343 per day for the first 4 days of the inpatient hospital services. The total for your stay is $1372 ($343 copayment x 4 days = $1372). Please note that the type of room does not affect the copayment amount. The inpatient hospital services fall within the Inpatient Hospital 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 inpatient hospital services provided from September 10, 2021, to September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 2, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 29,
2020, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the services at issue are covered by
Medicare. The Plan denied your request. The Plan says rules for payment for out-of-network care have not
been met.
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 (90834) provided on
September 29, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a polysomnography (95810).  You asked the Plan to pre-approve the polysomnography. You say that the enrollee was diagnosed with sleep apnea in 2009. You also say that the enrollee needs a sleep study in a lab to confirm his diagnosis so he can get supplies through his insurance. The Plan denied your request. The Plan says sleep testing is not supported to replace your positive airway pressure (PAP) machine. The Plan also says that sleep testing is not supported to start using a PAP machine you already have.  The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or sleep studies are not routinely indicated for patients treated with continuous positive airway pressure (CPAP) whose symptoms continue to be resolved with CPAP treatment.  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 polysomnography. Our reviewer says that this service does not meet the criteria for coverage. Our physician reviewer found the enrollee has purchased his own CPAP device and it is effective for him. Our reviewer also found that there is no need for a sleep study because the enrollee is being adequately treated with the current device and settings.  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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve a polysomnography (95810).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the office visits provided on August 25, 2021, and September 15, 2021  You asked the Plan to waive the copayments for the office visits. You say that you shouldn't have patient responsibility for these office visits. The Plan denied your request. The Plan says the proper copayments have been applied for a specialist visit.  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 Specialty Care Physician.     You have been asked to pay a $100 copayment for two office visits. An office visit with a Specialty Care Physician falls within the Physician/Practitioner services, including doctor's office visits 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 copayments for the office visits provided on August 25, 2021, and September 15, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on October 4, 2021.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this is not separately payable.
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, we have confirmed that code 71045
is a column II code to column I code 36573. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for an x-ray (71045) provided on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services provided on June 21, 2021.  You asked the Plan to pay for the services provided. You say that the test identifies the lesions to treat. The Plan denied your request. The Plan says the code is not supported in the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code 75710 is Angiography, extremity, unilateral, radiological supervision and interpretation. We looked at the file and the rules. We find that the service at issue was provided as part of a vascular procedure which includes a diagnostic angiography. The medical records provided do not show that the service was a distinct procedural service. Based on this information, we decided that Medicare rules for coverage have not been met.  The CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. We find that CPT code 75625 was not supported in the medical records. The records do not include an interpretation of an abdominal aortography. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on February 19, 2021.  You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 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 pay for a lumbar-sacral orthosis. Our reviewer says that the item at issue is not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided clinical notes do not include a lumbar-sacral orthosis in the plan. The documentation is insufficient to demonstrate that the enrollee in this case requires a lumbar-sacral orthosis to reduce pain by restricting mobility of the trunk, or to facilitate healing following an injury to the spine or related soft tissues, or to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on February 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiologic examination, abdomen; 1 view (CPT code 74018) provided to the enrollee on August 18, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is bundled to another service billed on the same day by the same provider.  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, we have confirmed that code 74018 is a column II code to column I code 74019. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, abdomen; 1 view (CPT code 74018) provided to the enrollee on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740) for tooth #31 provided on September 9, 2021.  You asked the Plan to pay for the crown. You say that this service was medically necessary for replacement of an ill-fitted oversized crown on tooth #31 and you would like to be reimbursed for it. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  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, crown (D2740) is limited to one procedure per tooth every five plan years. The record shows that you received a crown (D2740) on tooth #31 on April 24, 2020 and your crown benefit for tooth #31 has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth #31 provided on September 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation services (70450) provided on September 18, 2021.  You asked the Plan to waive the copayment for the ambulance transportation services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for Ambulance services.     The enrollee has been asked to pay a $300 copayment for ambulance transportation services. The Plan does not deny that these services were medically necessary, however, the copayment is still applicable. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation services (70450) provided on September 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on September 14, 2021.  You asked the Plan to pay for code 70544. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 7, 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 testing is not covered.  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 test at issue in this appeal, FISH (fluorescence in situ hybridization) testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 7, 2021.