Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for Freestyle test strips for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says these are not the preferred testing supplies.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for Freestyle test strips for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Ruxience (Q5119).
You asked the Plan to pre-approve Ruxience. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested drug has been prescribed for a not medically accepted indication.
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 Ruxience. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the record indicates that the enrollee has multiple myeloma. The Food and Drug Administration has not approved the requested drug for this indication. The Medicare-approved cancer compendia do not provide a positive citation for the use of the requested drug for this indication. No literature from Medicare-approved cancer journals was submitted with the request for consideration. 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 Ruxience have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Ruxience (Q5119).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 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 were billed incorrectly.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply.

We looked at the file and Medicare rules. Procedure code U0003 (Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) was billed with modifier -26 for payment of the professional component; however, this code has a PC/TC indicator of 9 and the professional component does not apply. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for initial observation care (CPT code 99220-AI) provided to the enrollee on October 5, 2020.
You asked the Plan to pay for initial observation care. You say that a corrected claim was submitted on February 12, 2021, with the correct modifier added. The Plan denied your request. The Plan says that they did not provide you an answer within the required timeframe.
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. Review of the record supports that this provider admitted the enrollee to observation status and that the modifier is also appropriate. No alternative denial rationale was provided to support non-payment of this claim. Therefore, we decided that the Plan has to pay for initial observation care (CPT code 99220-AI) provided to the enrollee on October 5, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan represented by code 70450 provided on March
18, 2021.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the CT scan represented by code 70450 provided on March 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from January 28, 2021, to February 24, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that there should only be one inpatient copayment because the enrollee was admitted to the hospital earlier in the month The Plan denied your request. The Plan says the inpatient care was covered as two separate hospital admissions, and therefore two separate copayments apply.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment for each medically necessary inpatient stay.
The enrollee has been asked to pay a $125 copayment for the inpatient care. The record indicates that the two inpatient hospital stays were covered as separate admissions. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from January 28, 2021, to February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80050) provided June 8, 2021.

You asked the Plan to pay for the lab services. You say that the blood work should be covered. The Plan denied
your request. The Plan says the code billed is not eligible for Medicare coverage.

The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by
Medicare.

We looked at the file and Medicare rules. The service billed was CPT code 80050. This is not a covered
service. No medical records were provided to support that the individual tests were medically necessary. Based
on this information, we decided that Medicare rules for coverage of a GHP have not been met. Therefore, the
Plan does not have to pay for the GHP Therefore, we decided that the Plan does not have to pay for lab services
(80050) provided June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000).

You asked the Plan to pay for foot orthotics. You say that the shoe inserts are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the steroid injections provided on March 2, 2021 and May 19, 2021.

You asked the Plan to waive the copayments for the steroid injections. You say that you were not informed you would be charged a fee for a treatment/observation room. The Plan denied your request. The Plan says you have been asked to pay 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 $275 copayment for Medicare-covered outpatient hospital and observation services. For these dates of service, you have been asked to pay the allowed amounts of the claims because these amounts are less than the standard $275 copayment for the steroid injections.

You have been asked to pay a $234.56 copayment for the steroid injections on each date of service. The steroid injections fall within the "Outpatient hospital 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 copayments for the steroid injections provided on March 2, 2021 and May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2751) for tooth # 11.
You asked the Plan to pre-approve a crown for tooth # 11. You say that you need these crowns as soon as possible. The Plan denied your request. The Plan says a crown for tooth # 11 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 for tooth # 11 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 for tooth # 11. Our reviewer says that the requested crown for tooth # 11 is not medically necessary. Our physician reviewer found the reason for the denial was that the documentation provided was insufficient. The reviewer found that the documentation provided was not sufficient to determine the prognosis of the root canal treatment of tooth # 11. Therefore, the reviewer found that, based on the provided documentation, the crown for tooth # 11 is not medically reasonable or necessary. 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 for tooth # 11 have not been met. Specifically, the file does not include an x-ray of the whole tooth. Therefore, we decided that the Plan does not have to pre-approve crowns (D2751) for tooth # 11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DyAnsys Primary Relief auricular electro-acupuncture device.
You asked the Plan to pre-approve a DyAnsys Primary Relief device. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says the item is not a Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a DyAnsys Primary Relief device have not been met. Specifically, the requested item is an electro-acupuncture device which is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a DyAnsys Primary Relief auricular electro-acupuncture device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2021, through April 5, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because your records show you did not have any acute medical findings which required inpatient care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the medical record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2021, through
April 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) on April 27, 2021, with a provider who has opted out of Medicare.
You asked the Plan to pay for an office visit. You say that you submitted a similar claim for the same service on a different date which was approved and reimbursed. The Plan denied your request. The Plan says rules for payment have not been met because the provider in this case has opted out of Medicare.
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 an office visit (99213) on April 27, 2021, with a provider who has opted out of Medicare
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.

You asked the Plan to pre-approve the services. You say that the plan made a mistake, and you are the one paying for it. The Plan denied your request. The Plan says acupuncture is only covered for low back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Acupuncture is being for polyneuropathy, which is a non-covered diagnosis. This service is only covered for chronic low back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcatheter therapy represented by code 37214, the intravascular ultrasound (additional noncoronary vessel) represented by code 37253, and the selective catheter placement represented by code 36245 provided from July 8, 2020 to July 9, 2020.
You asked the Plan to pay for codes 37214-59-78, 37253-78, and 36245-59-78. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that 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 37214 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 code 37214-59-78 has not been met.
Medicare rules also 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 37253 is Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (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 code 37253-78. Our reviewer says that the operative report does not include documentation of additional noncoronary vessel, and therefore cannot be verified as performed.
The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this case, our reviewer says that the documentation does not support this service as a separate procedure, and therefore, would not be billable with CPT 37226.
Therefore, we decided that the Plan does not have to pay for the transcatheter therapy represented by code 37214, the intravascular ultrasound (additional noncoronary vessel) represented by code 37253, and the selective catheter placement represented by code 36245 provided from July 8, 2020 to July 9, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a wheeled folding walker (E0143)
provided on June 14, 2021.

You asked the Plan to waive the coinsurance for a wheeled folding walker. You say that you have no use for
the item at issue and you were unaware you would be receiving a bill for it. The Plan denied your request. The
Plan says the correct coinsurance 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 20%
coinsurance for durable medical equipment, oxygen/oxygen equipment, and related supplies.

You have been asked to pay $17.13, or 20% of the Medicare-allowed charge of $85.69, for a wheeled folding
walker. A wheeled folding walker falls within the "Durable medical equipment (DME) and related 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 coinsurance for a wheeled folding walker
(E0143) provided on June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for rotary wing air transport (A0431) provided on
April 18, 2020.
You asked the Plan to pay for rotary wing air transport. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. Rotary wing ambulance service was paid in full by the no-fault automobile insurance company.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has [indicate the plan's method of coordination]. As the secondary insurer, the Plan cannot be held responsible for rotary wing air transport until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for rotary wing air transport (A0431) provided on April 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 29, 2020.

You asked the Plan to pay for physician's services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on December 4, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 29, 2020.