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

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 29, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that your wife called the ambulance after you became unconscious and not responding. You say after the medics arrived and worked on you that you spoke to your doctor who told you that everything was alright, and you would be fine. The Plan denied your request. The Plan says the service is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on January 29, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the femur x-ray provided on May 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 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 femur x-ray provided on May 4, 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 dental cleaning (D1110), fluoride (D1206) and oral
hygiene instructions (D1330) provided on February 25, 2021.

You asked the Plan to pay for the dental services. You say that you were having trouble finding a list of Plan approved
providers for dental care. The Plan denied your request. The Plan says this provider has chosen to
opt-out of Original Medicare, and therefore no payment can be made for the services provided.

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 can cover dental
services when they are received from a licensed dental provider who accepts Medicare patients in the United
States and has not opted out of Original Medicare.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a
provider who does not participate in the Medicare program are not covered under this benefit. Therefore, we
decided that the Plan does not have to pay for the dental cleaning (D1110), fluoride (D1206) and oral hygiene
instructions (D1330) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for IV therapy infusion services and Part B injectable provided on March 1, 2021.

You asked the Plan to adjust the coinsurance for IV therapy infusion services (96360, 96365, 96366, 96374) and Part B injectable (Q5104). You say that you don't feel the coinsurance was processed correctly. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B prescription Drugs. 

You have been asked to pay 20% coinsurance for IV therapy infusion services (96360, 96365, 96366, 96374) and Part B injectable (Q5104). IV therapy infusion services (96360, 96365, 96366, 96374) and Part B injectable (Q5104) fall within the Medicare Part B prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.

Therefore, we decided that the Plan does not have to adjust the coinsurance for IV therapy infusion services and Part B injectable provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 17, 2021, to March 31, 2021.

You asked the Plan to waive the copayment for podiatry services. You say that you had to go to a different podiatrist to find relief. You say that you should not have to pay for the first two office visits. The Plan denied your request. The Plan says the correct copayment has been 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 $40 copayment for podiatry services. 

You have been asked to pay a $40 copayment for podiatry services. The total amount you are being asked to pay is $80 ($40 + $40 = $80). Two office visits were provided; therefore, the correct copayments have been applied. Podiatry services fall within the podiatry services 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 specialist services provided by a participating provider on March 17, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on February 11, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99100). 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 the anesthesia services provided on February 11, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that that you have trialed Orthovisc. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met because Monovisc has not been trialed nor addressed.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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. Our reviewer says that that
the requested drug is not medically necessary. Our physician reviewer found that the Plan requires a trial of
drugs Orthovisc and Monovisc before they will approve the requested drug. The requested medication is a new
start. The provided records do not indicate that you have tried and failed the Plan's preferred alternatives. The
record does not indicate that you have a contraindication to, or would have an adverse effect from, the Plan's
preferred alternatives. The elements of the coverage criteria are not satisfied.
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 have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots (22551) provided on November 25, 2020.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service 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 20% coinsurance for each in-network surgical or observation room service you get at an outpatient hospital. Additionally, your in-network yearly maximum out-of-pocket amount is $5,900.00.

You have been asked to pay a $1,444.02 coinsurance for the outpatient surgery provided. This is the Plan's allowed amount for this service as you have now met the yearly in-network maximum out of pocket cost required. Additionally, this amount is less than the applicable coinsurance for this service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots (22551) provided on November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laminectomy procedure.

You asked the Plan to pre-approve a laminectomy procedure. You say that the requested laminectomy procedure is medically necessary. The Plan denied your request. The Plan says the requested laminectomy procedure 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 pre-approve a laminectomy procedure. Our reviewer says that the requested laminectomy procedure is not medically necessary. Our physician reviewer found the enrollee is diagnosed with spondylolysis lumbar region. Criteria for spine surgery have not been met. There is no documentation of adequate conservative measures for back pain to include physical therapy. There are no red flags for surgery at this time. 

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 laminectomy procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a laminectomy procedure.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided outside the United States on January 13, 2021 to February 6, 2021.

You asked the Plan to pay for the hospital services. You say that the service was an emergency and should be covered in full. The Plan denied your request. The Plan says the plan already paid the Medicare allowable amount. No further payment is due.

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. The plan contract states that you are covered for emergency care worldwide. The plan will only reimburse up to the Medicare allowable rates. 

We looked at the plan contract, the file, and Medicare rules. The plan already reimbursed the Medicare allowed amount of $220.62. The remaining amount and the $50 copayment remain the enrollee's responsibility as the plan only reimburses up to the Medicare allowed amount. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services provided outside the United States on January 13, 2021 to February 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for paravertebral facet joint injections (64494) provided on March 15, 2021.
You asked the Plan to pay for paravertebral facet joint injections. You say that this is supported in the records. The Plan denied your request. The Plan says this exceeds MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for paravertebral facet joint injections (64494) provided on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from October 8, 2019 to October 14, 2019.
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 records do not support the billing of DRG 871 and diagnosis codes A41.9 and N17.9 .
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with . 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 these services. Our reviewer says that the records do not support the billing of DRG 871 and diagnosis codes A41.9 and N17.9 . Our physician reviewer found the enrollee presented for evaluation on October 8, 2019 and reported cough, nausea, vomiting, diarrhea, and abdominal pain. She was admitted for the management of pneumonia and received intravenous antibiotics and fluids. She did not experience persistent hypotension or ongoing hemodynamic instability. The platelet count was normal. Serum creatinine elevation is attributable to volume depletion. Elevation of the total bilirubin level is insufficient to qualify as evidence of potentially life-threatening organ dysfunction. Despite concern for sepsis, she did not experience life-threatening organ dysfunction related to a dysregulated host response to infection. There is insufficient evidence in the records available for review to substantiate the diagnosis codes for Sepsis and Acute kidney failure. The records do not support the billing of DRG 871 and diagnosis codes A41.9 and N17.9. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from October 8, 2019 to October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (96372) provided on March 29, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 

We looked at the file and Medicare rules. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly and are not payable, the drug administration code, 96372, also cannot be paid. 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 the services (96372) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor and garments provided on April 22, 2021.

You asked the Plan to pay for intermittent limb compression device (E0651) and garments (E0667). You say that the Plan should pay this claim. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis and payment would have been included in the facility prospective payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. 

Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item was used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compressor and garments provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 10, 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 procedure code 99291 is not supported.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
the first 30-74 minutes of critical care services spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on April 28, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $35 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist visit 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 specialist services provided by a participating provider on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 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 laboratory services provided on April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain without dye rendered on April 2, 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 procedure code 70450 is not separately payable.

The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable. 

The provider submitted a claim for procedure codes 70450 (CT head/brain without dye) and 70460 (CT head/brain with dye). Code 70450 is a column II code with a modifier indicator of 0 when billed with column I code 70460. Code 70450 is not separately payable. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain without dye rendered on April 2, 2021.