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

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Coflex Interspinous device in the setting of spinal surgery have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Coflex device is experimental. More research is needed to show safety and efficacy. Similar devices have had high failure rates. Our physician reviewer found that the enrollee condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Coflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.
You asked the Plan to pre-approve additional transportation trips. You say that you need transportation for
medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of
transportation trips allowed per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia service (99100) provided on March 16, 
2021. 
 
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this code is always 
bundled for payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled into payment for 
other services.  
 
We looked at the file and Medicare rules. This code is always bundled for payment and is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been 
met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided 
on March 16, 2021.
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 22, 2021.
You asked the Plan to pay for the dental service. You say that you feel that you did not receive this service. You say that the dentist was in and out so fast. You also say that you feel you should not have to pay for a service that you did not receive. The Plan denied your request. The Plan says coverage for a comprehensive oral exam is limited to once every 36 months.
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 services is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral exam that you received on November 4, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical notes do not indicate any skilled needs. 
 
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 pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 8, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you left and did not get the testing done. You say you should not be responsible for the copayment. 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 $120 copayment for Medicare-covered emergency room visits. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows a brief physical exam was completed. 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 emergency room visit provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on May 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 services provided on May 13, 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 electrocardiogram services (93010) provided on February 20, 2021.
You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.
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 93010 is a column II code to column I code 12001. 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 the electrocardiogram services (93010) provided on February 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on July 29, 2020.
You asked the Plan to pay for the laboratory test. You say that the service should be covered. 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 enrollee'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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted special service (99199) and additional supplies, materials, and clinical staff time (99072) provided on April 15, 2021.
You asked the Plan to pay for the unlisted special service and additional supplies, materials, and clinical staff time. You say that you would like these claims reprocessed based on the medical documentation submitted. The Plan denied your request. The Plan says these claims have denied correctly.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. The CPT Code Manual definition of code 99199 is unlisted special service, procedure or report.
We find that CPT code 99199 and 99072 is not supported in the medical record. Specifically regarding 99072, CPT code 99072 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99072. Regarding 99199, there is no operative report submitted to indicate what exactly this code is describing. Without this narrative explanation, this code will be denied. Based on this information, we decided that Medicare rules for coverage of the unlisted special service and additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted special service (99199) and additional supplies, materials, and clinical staff time (99072) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), amalgam (D2150), anterior resin-based composite (D2331), posterior resin-based composite (D2392), simple extraction (D7140), surgical extraction (D7210), and removal of residual tooth roots (D7250) provided on February 8, 2021.
You asked the Plan to pay for the dental services. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are purely dental in nature and are unrelated to the limited clinical indications. The Plan also says that these services are not eligible for coverage under the medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), amalgam (D2150), anterior resin-based composite (D2331), posterior resin-based composite (D2392), simple extraction (D7140), surgical extraction (D7210), and removal of residual tooth roots (D7250) provided on February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 25, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you had to return to the 
hospital for a bacterial infection and the services were not emergent. 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 $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on June 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 8, 2021, to May 13, 2021.
You asked the Plan to pay for the home health services. You say that you would like the plan to waive the requirement for a provider to be a certified Medicare provider due to extenuating circumstances related to the coronavirus pandemic. The Plan denied your request. The Plan says the provider in this case is not a Medicare enrolled provider. The Plan also says that the services are not eligible for reimbursement for the rendered Medicare services.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 8, 2021, to May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided February 19, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the required documentation was not received.
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. In this case, the billed documentation support that a second surgeon was used during this procedure. However, operative notes from the second surgeon were not provided to corroborate the services as billed. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (0242U) provided on June 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 lab services (0242U) provided on June 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 inpatient hospital services provided from May 17, 2021, to May 23, 2021.You asked the Plan to pay for the inpatient hospital services.
You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the primary diagnosis code was inappropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The claim shows the services at issue were billed with a primary diagnosis code F01.51, vascular dementia with behavioral disturbance. We looked at the file and the rules. Based on this information, we decided that the rules for sequencing have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from May 17, 2021, to May 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on March 29, 2020.
You asked the Plan to pay for the inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the claim was submitted after the 12-month timeframe.
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 inpatient hospital care was not filed until May 26, 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 the initial hospital care (99223) provided on March 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services provided on May 28, 2021.
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you are only covered for up to two dental extractions per calendar year. The Plan says they have already issued reimbursement for two extractions you received on May 28, 2021. You are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. In addition, there is no coverage for therapeutic parenteral drug, single administration, intravenous moderate (conscious) sedation/analgesia-first 15 minutes, or intravenous moderate (conscious) sedation/analgesia-each subsequent 15-minute increment.
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. We looked at the file, the Plan's contract and Medicare rules. The Plan contract says you are only covered for up to two dental extractions per calendar year. The Plan says they have already issued reimbursement for two
extractions you received on May 28, 2021. You are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. In addition, there is no coverage for therapeutic parenteral drug, single administration, intravenous moderate (conscious) sedation/analgesia-first 15 minutes, or intravenous moderate (conscious) sedation/analgesia-each subsequent 15-minute increment. Therefore, we decided that the Plan does not have to pay additionally for the dental services provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test represented by code G0483 provided on May
20, 2021.
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the records do not support the billing of code G0483.
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 G0483 is Drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain
evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we
decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the
Plan does not have to pay for the drug test represented by code G0483 provided on May 20, 2021.