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

 We decided that the Plan does not have to pay for the skilled nursing facility care provided from June 20, 2021, to July 19, 2021.  You asked the Plan to pay for the SNF care provided from July 4, 2021, to July 19, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled services on the dates of service in this case.  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 pay for the SNF care provided from July 4, 2021, to July 19, 2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  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 SNF care provided from July 4, 2021, to July 19, 2021, have not been met. Specifically, the file indicates that the enrollee did not receive daily skilled services on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility care provided from June 20, 2021, to July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure codes 63081, 22554, 22845, 22854) provided to the enrollee on February 9, 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 the records do not support the services 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, the CPT Code Manual definition of the denied codes is:  CPT 63081:  Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment    CPT 22554:  Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2  CPT 22845:  Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)  CPT 22854:  Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)  We asked our coder 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the operative report does not documentation of the various procedures described by the denied codes. For CPT 63081, the documentation should document the percentage removed to confirm partial removal. For CPT 22554, there is no documentation of arthrodesis in the operative report. As CPT 22854 and CPT 63081 are not confirmed to have been performed, the add-on codes CPT 22845 and 22854 are not covered.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure codes 63081, 22554, 22845, 22854) provided to the enrollee on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on
July 29, 2021.
You asked the Plan to pay for the eye exam. You say that the representative informed you that exams are paid
for and glasses are reimbursed up to $150. You say that you are appealing the decision not to reimburse you.
The Plan denied your request. The Plan says this service is not covered out of network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers this service when it is received from a network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the eye exam have not been met. Specifically, the eye exam was not received from a network
provider. Therefore, we decided that the Plan does not have to pay for the eye exam provided by an out-of-
network provider on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Imfinzi  You asked the Plan to pre-approve Imfinzi. You say that the patient is unable to tolerate chemotherapy and he is now due for immunotherapy. The Plan denied your request. The Plan says use of this drug is not supported for the patient's condition.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Imfinzi. Our reviewer says that the patient does not meet criteria for off-label usage of this drug. Our physician reviewer found this patient did not receive platinum-based therapy with radiation, so the requested use of Imfinzi is not FDA-approved for the enrollee's diagnosis.  The doctor found that the use of this drug for the patient's condition is not supported by one of the major drug compendia or by. clinical reasearch   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oncology (thyroid) gene expression analysis services provided on July 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the oncology (thyroid) gene expression analysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 oncology (thyroid) gene expression analysis services provided on July 3, 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 special anesthesia services rendered on November 6,
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 separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for
the special anesthesia services rendered on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70544) provided August 31, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed
and 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 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
radiology services (70544) provided August 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiograph (99308) provided June 15, 2021.
You asked the Plan to pay for the echocardiograph. You say that this service was medically necessary. The
Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 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 99308
is a column II code to column I code 33361. 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 echocardiograph (99308) provided June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (52442) provided March 30, 2021.
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The
Plan denied your request. The Plan says the code billed cannot be paid.
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 code 52442 is not supported in the medical record. Specifically, the procedure code does not
appear on the list of services covered when performed in an ambulatory surgical center (Medicare ASC
Addendum AA).
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been
met. Therefore, we decided that the Plan does not have to pay for surgical services (52442) provided March 30,
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periapical radiographic image (D0230) provided by an out-of-network provider on July 9, 2021.
You asked the Plan to pay for a periapical radiographic image. You say that when you signed up for this plan you asked if your current doctor was in-network. You say that you were told that they were in-network The Plan denied your request. The Plan says this claim has been correctly processed.
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. The Plan covers one periapical radiographic image per calendar year. We looked the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periapical first radiographic image have already been exhausted. Therefore, we decided that the Plan does not have to pay for a periapical radiographic image (D0230) provided by an out-of-network provider on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient infusion therapy services provided on August 27, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient infusion therapy services. You say that the service performed was medically necessary and justified. You request the Plan to overturn the denial and process the claim for immediate payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 outpatient infusion therapy services provided on August 27, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 19, 2021.  You asked the Plan to pay for the dental service. You say that you were not aware that this service was only covered once every 3 plan years. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been 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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on June 27, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 19, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for laboratory services (procedure code 84443) provided to the enrollee on July 26, 2021.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says that Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.  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. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has mixed hyperlipidemia. Thyroid stimulating hormone (TSH) was tested. As hyperlipidemia can be caused or exaggerated by hypothyroidism, screening is appropriate in this situation as it is part of a standard workup for hyperlipidemia. Therefore, the TSH will be considered 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 services have been met. Therefore, we decided that the Plan has to pay for laboratory services (procedure code 84443) provided to the enrollee on July 26, 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: Favorable

 We decided that the Plan has to pay for initial observation care after the emergency room evaluation (99220) rendered on July 28, 2021.  You asked the Plan to pay for initial observation care after the emergency room evaluation. You say that the provider for this service was the physician on call at the time. The Plan denied your request. The Plan says that the services were not referred by a network provider or rendered in a participating facility. The Plan also says they have determined that these services were not urgent or emergent, nor were they approved in advance.  The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health.   We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for initial observation care after the emergency room evaluation (99220) rendered on July 28, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a portable ventilator. You say that you need this device to improve your quality of life. The Plan denied your request. The Plan says you do not meet Medicare criteria for this device.  The Plan follows Medicare rules. Medicare rules say that that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition. There must be enough detailed information in the medical record to justify the treatment selected.  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 portable ventilator. Our reviewer says that a portable ventilator is not medically necessary for you. Our physician reviewer found the record indicates that you have chronic respiratory failure from chronic obstructive pulmonary disease.  The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The doctor says that you could be treated with a Bilevel positive airway pressure device, which has been recommended by the Plan.  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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays on April 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code A4550 (surgical trays) has a status indicator of
B and no separate payment. Therefore, we decided that the Plan does not have to pay for the surgical trays on
April 7, 2021
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) and wheelchair van mileage (S0209) provided on May 5, 2021.  You asked the Plan to pay for the transportation services. You say that the enrollee was in a rehabilitation (rehab) center. You say that the enrollee would not have been able to go to their doctor's appointment otherwise. You also say that the enrollee was diagnosed with additional heart condition prior to admission to rehab from inpatient hospital that required constant monitoring. The Plan denied your request. The Plan says wheelchair van (chair car) transportation is not covered by Medicare even if provided by an ambulance company.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) and wheelchair van mileage (S0209) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction services provided August 16, 2021.  You asked the Plan to pay for the refraction services. You say that while at your yearly eye check-up the doctor told you that the lens in your left eye was dirty and scratched. You have macular degeneration and he thought you might see better if it were cleaned and polished. The Plan denied your request. The Plan says the claim was processed correctly as the records show that this was a medical vision check and not a routine exam.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a participating provider and part of a routine exam.  We looked at the file and the Plan's rules. Eye refractions are covered when performed by a participating provider and as part of a routine exam. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided August 16, 2021.