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

 We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 31, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that there should not be a copay. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services.   You have been asked to pay a $250 copayment for the ambulance services. This service falls within the ambulance 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 the ambulance services provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99213, 99204) provided on May 27, 2021 to July 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for office visits. You say that this is supported in the records. The Plan denied your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office visits (99213, 99204) provided on May 27, 2021 to July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, one way (rotary wing) (A0431) provided on July 7, 2021.

You asked the Plan to pay for the transportation service. You say that this should be covered. The Plan denied your request. The Plan says services that were not rendered are not covered.

The Plan must follow Medicare rules. Medicare rules say that no Medicare payment determination will be made when the flight is aborted any time before the beneficiary is loaded onboard. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation service have not been met. Specifically, the file does not show that the enrollee was transported by an air ambulance. The file also shows that the trip was aborted before the enrollee was loaded onto the air ambulance. Therefore, we decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, one way (rotary wing) (A0431) provided on July 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain provided August 2, 2021.  You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim is missing a necessary modifier that is required for payment.  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 70450 is computed tomography, head or brain; without contrast material.  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 CT scan of the head or brain. Our reviewer says that the documentation does not support payment for the code billed 70450-26. Our reviewer found that the billing history and medical records submitted, indicate the same service, 70456-26. was performed by another provider as well on August 2, 2021, and was billed to the Plan and reimbursed. In order for 70456-26 billed by a second provider to be considered for reimbursement by the Plan, a necessary modifier must be added to 70456-26.  Because the necessary modifier has not been added to 70456-26, no additional reimbursement is allowed.  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 CT scan of the head or brain have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain provided August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on June 7, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. 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 office visit provided on June 7, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 28, 2021.  You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with how the claims were processed and you should only owe a $25 copayment. 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 outpatient surgery, including services provided at hospital outpatient facilities.  The record shows that you received arthrocentesis at an outpatient hospital facility on October 28, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the total allowed amount of $234.56, which is less than the $275 copayment.    You have been asked to pay $234.56 for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 9.  You asked the Plan to pre-approve a crown. You say that the crown is medically necessary. The Plan denied your request. The Plan says a crown for tooth # 9 is not medically necessary.  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 a crown when the services are medically necessary and reasonable.   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 crown. Our reviewer says that a crown for tooth # 9 is not medically necessary. Our physician reviewer found that the documentation provided does not show that there is extensive breakdown of tooth #9, and the endodontic access is not significant enough to require full coverage to restore the tooth properly.  If a tooth does not need to gain strength from a restoration, then a conventional composite restoration would be adequate to properly restore the tooth.  Given the presentation of the tooth, there is no necessity for a crown and the Plan criteria for crowns has not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Specifically, the file shows that tooth # 9 does not have significant breakdown that would warrant a full coverage crown. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 9.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Aranesp. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee is noted to have anemia due to Myelodysplastic syndromes (MDS). The documentation does not support that the enrollee has tried and failed Retacrit or Procrit. While the enrollee has received two single doses of Procrit during hospitalizations, there is no evidence that the enrollee has received a formal course of Procrit with monitoring. There is no evidence that the enrollee is allergic to or intolerant of Retacrit and Procrit. There is no documentation as to why Retacrit or Procrit would not be expected to be safe and effective for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization was not obtained.

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 referring provider 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 lab services provided on January 12, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 19, 2020.
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 claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until October 14, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 19, 2020.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ambulance service, basic life support, emergency transport (A0429), ground mileage (A0425), and supplies (A0382) provided on April 6, 2021.  You asked the Plan to pay for the transportation services. You say that you understand your copayment is $250 for the services. You also say that you should not be liable for the entire amount that you are being charged. The Plan denied your request. The Plan says that the enrollee has no liability for the denied services. The Plan also says that the non-contracted provider is balance billing.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the transportation services by a contract provider. The file does not show that the Plan provided notice that the transportation services would not be covered. Under Medicare rules, this means the transportation services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the ambulance service, basic life support, emergency transport (A0429), ground mileage (A0425), and supplies (A0382) provided on April 6, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 14, 2020.
You asked the Plan to pay for the injection, self-administered drug, Lorazepam, and Morphine. You say that hospice benefits were effective from July 14, 2020, to July 15, 2020. You also say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 12, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you did not know that you needed to use doctors listed on your ID card. 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 a $45 copayment for each specialist visit.   You have been asked to pay a $45 copayment for the specialist office visit. Please note that the copayment is the same for any specialist that you choose. Specialist office visits fall 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 copayment for a specialist office visit provided on August 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology with gross and microscopic examination of colorectal polyp (88305) provided on March 29, 2021.

You asked the Plan to pay for the tissue biopsy. You say that the services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's diagnosis does not support medical necessity of the service that was rendered.

The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM codes that are not listed do not support medical necessity. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tissue biopsy have not been met. Specifically, the enrollee's diagnosis code is not listed and therefore is not medical necessary. Therefore, we decided that the Plan does not have to pay for the surgical pathology with gross and microscopic examination of colorectal polyp (88305) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator (CPT Code E0745) provided on
July 26, 2020, by an out-of-network provider.
You asked the Plan to pay for the DME. You say that the documentation clearly shows medical necessity based
on the doctor's review of the patient. You state that you provided services based on the prescription and the
notes you received from the doctor. The Plan denied your request. The Plan says it is unknown if the telephonic
interview is conducted by a physician or one of your employees. The Plan states some enrollees have indicated
that they never spoke to the ordering physician documented in the records. The Plan states there are no
documented attempts to contact this enrollee's local physician.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. This provider prescribes DME
without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator (CPT Code E0745)
provided on July 26, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22870, 22869).
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 pre-approve a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition. 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 Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer (22870, 22869).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, provided on January 7, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was never transported to the hospital. You also say that because of this, the family should not be charged for the bill. 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 member'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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99212) chiropractic manipulative treatment (98941) provided April 5, 2021.  You asked the Plan to pay for the chiropractic visit. You say that per Medicare guidelines, the services with a GA modifier should deny PR and not CO. The Plan denied your request. The Plan says the claim was billed with a GA modifier. Modifier GA is for spinal manipulation considered maintenance or non-payable by Medicare.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.  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. The claim was billed with a GA modifier.  The GA modifier is for spinal manipulation considered maintenance or non-payable by Medicare. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99212) chiropractic manipulative treatment (98941) provided April 5, 2021.