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

 We decided that the Plan does not have to pay for the endoscopic stone removal (43264) provided on September 28, 2021.  You asked the Plan to pay for the endoscopic stone removal (43264). You say that a stent was removed, and multiple large stones were extracted followed by a balloon sweep. You say that the stone extract procedure should not be considered bundling, and payment should be reconsidered. The Plan denied your request. The Plan says bundled services are not separately payable.    The Plan must follow Medicare rules. Medicare rules say that if Field 21 contains an indicator of "3," and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the endoscopic stone removal (43264) have not been met. Specifically, the record indicates that the endoscopy procedures on this claim have an indicator of 3. The record also indicates that the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy has been paid. Therefore, we decided that the Plan does not have to pay for the endoscopic stone removal (43264) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided from September 8, 2021, to September 30, 2021.  You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee has opted out of the Medicare program.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services provided from September 8, 2021, to September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a face-down positioning table and associated costs provided on July 22, 2021.  You asked the Plan to pay for a face-down positioning table. You say that this was medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.       The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a face-down positioning table and associated costs provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for preventive medicine counseling (99401) provided on October 29, 2021.  You asked the Plan to pay for preventive medicine counseling. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that a status indicator of "N" under the Physician Fee Schedule indicates that the code in question is not covered by Medicare.   We looked at the file and Medicare rules. Code 99401 is assigned a status indicator of "N" under the Physician Fee Schedule, which means that this code is not covered by Medicare.   Based on this information, we decided that Medicare rules for coverage of preventive medicine counseling have not been met. Therefore, we decided that the Plan does not have to pay for preventive medicine counseling (99401) provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that this would be helpful for your medical condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is being specifically requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiovascular genetic risk assessment testing provided to the enrollee on November 13, 2020.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this is not medically necessary.  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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found only a Lipid Panel, Cholesterol, serum or whole blood, total, Lipoprotein, direct measurement, high density cholesterol and Triglycerides are covered once every 60 months for screening for cardiovascular disease.  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 testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic risk assessment testing provided to the enrollee on November 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI provided on August 18, 2021.  You asked the Plan to waive the copayment for an MRI. You say that you have never been charged in the past for an MRI and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for diagnostic radiology.  You have been asked to pay a $275 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an MRI provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on September 9, 2021.  You asked the Plan to waive the copayment for an emergency room visit. You say that you were stuck outside of the U.S. due to the pandemic and had to receive care. The Plan denied your request. The Plan says the proper copayment for this service was applied.  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 $90 copayment for each non-Medicare covered emergency room visit outside the United States and its territories. The total amount billed was $34.56 which is less than the copayment amount of $90. Therefore, only $34.56 was charged as a copayment.  You have been asked to pay a $34.56 copayment for an emergency room visit. An emergency room visit falls within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the annual wellness visit provided on October 4, 2021.  You asked the Plan to pay for the annual wellness visit. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee received an annual wellness visit on February 24, 2021, that was paid for by the Plan.  The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on October 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa injections.  You asked the Plan to pre-approve Euflexxa injections. You say that this is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the previous Euflexxa injections did not provide pain relief.  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 Euflexxa injections. Our reviewer says that the requested injection services are not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 74-year-old female with a history of chronic bilateral knee pain due to osteoarthritis. She has received previous Euflexxa therapy in 2020. She reports knee pain despite the viscosupplementation series of 3 injections. Her provider has requested a repeat series of Euflexxa injections.  According to the Medicare guidelines, a repeat series of Euflexxa injections may be allowed when there is documentation of significant improvement in pain and functional capacity from the prior series of injections and the last injection (in a prior course) was given at least six (6) months ago. In this case, previous Euflexxa therapy did not prove to be beneficial. The review has determined that the documentation does not support that Euflexxa is medically reasonable or necessary for the patient. The documentation does not support that another series of Euflexxa is safe and effective for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on August 18, 2021.  You asked the Plan to pay for an office visit. You say that you submitted the medical records to appeal for the denial because it was medically necessary. The Plan denied your request. The Plan says there was no approval for a non-participating provider with no evidence of an emergency situation.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.      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 an office visit. Our reviewer says that the requested service from an out-of-network provider was not an emergency or urgent medical reason. Our physician reviewer found the record indicates that the enrollee has cardiomyopathy and an implanted defibrillator. The record indicates that the enrollee was presented for a routine foreseeable follow-up and was doing well without chest pain. The record does not indicate that the enrollee was seen for either an emergent or urgent medical reason. The record does not indicate that the care was needed at the time it was received and could not have been delayed pending return to the area of residence.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit provided on August 18, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lattice Stereotactic Body Radiation Therapy (SBRT).  You asked the Plan to pre-approve Lattice SBRT. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that SBRT services are subject to the criteria listed in the Medicare rules section. 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 Lattice SBRT. Our reviewer says that the requested radiation therapy services are not medically reasonable and necessary. Our physician reviewer found This patient has a large primary soft tissue sarcoma of the thigh, along with 5 pulmonary nodules. She declined surgery and was offered palliative radiation in an effort to afford tumor control and facilitate chemotherapy administration. Lattice radiotherapy, a form of 3-dimentsional spatially fractionated radiotherapy, is a specific technique in which radiation is delivered via a lattice to deliver heterogeneous doses, generally with high dose per fraction to large tumors. Its use with SBRT has been investigated in a Phase I study of 22 patients, but not considered a standard of care approach. The case file provides no evidence basis for SBRT, Lattice or SBRT with Lattice and describes no consensus guidelines describing this as an accepted standard of care. The criteria for coverage in the LCD have not been met. The requested radiation therapy is not 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 Lattice SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Lattice Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 30, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare does not pay any provider, supplier, vendor separately for services furnished to the beneficiary in preparation for, or for a procedure or surgery.  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 71046 is "Radiologic examination, chest; 2 views."  We find that CPT code 71046 is not supported in the medical record. Specifically, as this was done for preparation for a surgery, it cannot be paid separately. 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 imaging services provided to the enrollee on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015), the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report (92133), and the ophthalmological medical examination and evaluation (92004) rendered by the OON provider on June 2, 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 eye refraction (92015), the scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report (92133), and the ophthalmological medical examination and evaluation (92004) rendered by the OON provider on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a mammography (77063, 77067) provided on September 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for mammography. You say that you are appealing with supporting records. The Plan denied your request. The Plan says you are appealing with supporting records.  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 a mammography (77063, 77067) provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the endoscopy (43246) provided on August 31, 2021.  You asked the Plan to pay for the endoscopy (43246). You say that the patient had multiple exams on this date and the attached reports support the level of service. You say that the claim should be reconsidered. The Plan denied your request. The Plan says that HCPCS code 43246-AS-59 exceeded the allowable units of service.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that one unit of CPT code 43246 was already paid. The records do not support that multiple units of CPT code 43246 were billed on this date of service or that one was already paid. It is the burden of the Health Plan to substantiate their denial with evidence and the denial based on exceeding the allowable units has not been substantiated. Therefore, we decided that the Plan has to pay for the endoscopy (43246) provided on August 31, 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 24, 2020, by an out-of-network provider.  You asked the Plan to pay for psychotherapy services. You say that procedure code 90834 is 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 June 24, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nasal interface coded A7034, the headgear coded A7035, filter coded A7038, and tubing coded A4604 provided on August 24, 2021.  You asked the Plan to pay for the nasal interface, the headgear, filter, and tubing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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.  We find that CPT codes A7034, A7035, A7038, and A4604 are not supported in the medical record. Specifically, these codes were submitted with modifier NU, indicating new equipment. These codes were submitted without additional modifiers. Suppliers must add a KX modifier to codes for equipment and accessories.  Based on this information, we decided that Medicare rules for coverage of the nasal interface, the headgear, filter, and tubing have not been met. Therefore, we decided that the Plan does not have to pay for the nasal interface coded A7034, the headgear coded A7035, filter coded A7038, and tubing coded A4604 provided on August 24, 2021.