Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided August 19, 2021.  You asked the Plan to pay for the intraoral x-rays. You say that you were told this was a network provider. The Plan denied your request. The Plan says the claims from this date of service have been given a one-time exception to be provided in-network, however, the intraoral x-rays are not a covered service.  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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography guidance (77014) provided on March 23, 2021.  You asked the Plan to pay for computed tomography guidance. You say that this is a payable code. The Plan denied your request. The Plan says this is not supported in the records.  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 rules also 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.  In this case, the CPT Code Manual definition of code 77014 is computed tomography guidance for placement of radiation therapy fields.  We find that CPT code 77014 is not supported in the medical record. Specifically, no legible records have been submitted for the date of service at issue. Without this information, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of computed tomography guidance have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography guidance (77014) provided on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from June 4, 2021, through June 7, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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 $310 copayment per day, per admission, for days 1-7 for inpatient hospital care.   You have been asked to pay $930 ($310 copayment x 3 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from  June 4, 2021, through June 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the regadenoson injection provided on August 4, 2021.  You asked the Plan to waive the coinsurance for the regadenoson injection. You say that the injection was a part of the stress test, and you should only be charged a $40 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 20% coinsurance for in-network Medicare Part B covered drugs.   You have been asked to pay $320.70 which is 20% of the allowed amount for the regadenoson injection. The allowed amount is $1,603.52. ($1,603.52 x 20% = $320.70). The regadenoson injection falls within the "Medicare Part B prescription drugs" benefit category. The record shows the injection is considered a separate 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 regadenoson injection provided on August 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided from March 30, 2021, through March 31, 2021.  You asked the Plan to pay for physical therapy services. You say that the member was not in hospice on these dates of service. 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 March 24, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from March 30, 2021, through March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mechanical traction therapy (97012) and the electrical stimulation (G0283) provided on August 6, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services rendered in this case are not a covered benefit under the enrollee's contractual policy.  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 records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy (97012) and the electrical stimulation (G0283) provided on August 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services rendered on July 14, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that a clinical psychologist must have a referral and consult from the beneficiary's primary care physician.   We looked at the file and Medicare rules. There is no documentation of a referral from the enrollee's primary care physician. 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 psychotherapy services rendered on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cranioplasty services coded 62145, the secondary repair of dura for cerebrospinal fluid leak coded 61618, and the burr hole(s); for implanting coded 61210 provided on June 13, 2021.  You asked the Plan to pay for the cranioplasty services, the secondary repair of dura for cerebrospinal fluid leak, and the burr hole(s); for implanting. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes 62145, 61618, and 61210 are not supported in the medical record. Specifically, the operative report did not include documentation of cranioplasty for skull defect with reparative brain surgery; therefore, code 62145 cannot be verified. The operative report did not include documentation of a secondary repair of the dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts); therefore, code 61618 cannot be verified. The operative report did not include documentation of a burr hole(s) for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure); therefore, code 61210 cannot be verified.  Based on this information, we decided that Medicare rules for coverage of the cranioplasty services, the secondary repair of dura for cerebrospinal fluid leak, and the burr hole(s); for implanting have not been met. Therefore, we decided that the Plan does not have to pay for the cranioplasty services coded 62145, the secondary repair of dura for cerebrospinal fluid leak coded 61618, and the burr hole(s); for implanting coded 61210 provided on June 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a cone beam CT image capture of one full dental arch (D0382) provided on September 20, 2021.  You asked the Plan to pay for a cone beam CT image. You say that the service at issue was a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.  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, the requested item or service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam CT image capture of one full dental arch (D0382) provided on September 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services provided on July 18, 2021.  You asked the Plan to pay for ambulance 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. 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 ambulance services provided on July 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a PET scan.  You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan denied your request. The Plan says a PET scan is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that a PET scan is not medically necessary. Our physician reviewer found this request is not for an oncologic indication (the citation listed above). Otherwise, CMS/Medicare only covers a PET/CT scan of the brain to differentiate between Alzheimer's Dementia (AD) and Frontotemporal Dementia (FTD) in patients who meet diagnostic criteria for both conditions (when additional requirements are met). The enrollee in this case is suspected of having a cognitive impairment. There was a higher suspicion of AD given a family history. However, the records did not support/suggest that that the enrollee is suspected of having both AD and FTD. Nor did he meet diagnostic criteria for both conditions. In as much, the requirements for coverage of a PET/CT of the brain for dementia would also not have been met in this case.   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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.      We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic procedures (97110) provided January 7, 2021 to July 8, 2021.  You asked the Plan to pay for the chiropractor services. You say that most visits were $70 and were paid by the same form of payment on that day. Those not on the credit cards were paid by cash. The Plan denied your request. The Plan says this service is not a covered benefit.  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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic procedures (97110) provided January 7, 2021 to July 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services provided on June 23, 2021.  You asked the Plan to pay for ophthalmological 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. 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 ophthalmological services provided on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 12, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that 911 was called because you passed out due to low blood sugar. You say emergency medical service (EMS) took your blood sugar level, which was less than 30 and they revived you with juice. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. If no transport of a Medicare beneficiary occurs, then there is no Medicare covered services.    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 August 12, 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 (A0998) provided on August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm (J3590).  You asked the Plan to pre-approve Aduhelm. The Plan denied your request. The Plan says the use of Aduhelm in this member is not reasonable and necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and Drug Administration (FDA) approved 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 Aduhelm. Our reviewer says that Aduhelm (J3590) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that the magnetic resonance imaging (MRI) showed diffuse age-related microvascular disease without localization. The primary source records provided are insufficient to support a diagnosis of Alzheimer's disease. Our reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm (J3590).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge services rendered on February 6, 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 99239 is not supported.  The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is payable per patient per hospital stay.   We looked at the file and Medicare rules. The file shows that code 99239 (hospital discharge day management) was billed by another physician for the same date of service and paid by the Plan.       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 hospital discharge services rendered on February 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 5, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says a physician's office, clinic, outpatient clinic, outpatient surgery center is not a covered destination. The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. An outpatient clinic is not a covered destination.   The services you have asked the Plan to pay for are ambulance transport services to an outpatient clinic. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the x-ray (73564) provided on September 3, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that you would like reconsideration because this x-ray was rendered in the same building as the provider's office. The Plan denied your request. The Plan says the $10 copayment applied to this service is correct.  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 $10 copayment for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $10 copayment for the x-ray. This x-ray falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for the x-ray (73564) provided on September 3, 2021.