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

 We decided that the Plan does not have to pay for radiology services (70450) provided September 20, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and is not separately payable.  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. 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 radiology services (70450) provided September 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the computed tomography (CT) scan of the abdomen and pelvis (74176) provided on September 14, 2021.  You asked the Plan to pay for the CT scan of the abdomen and pelvis. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says that this claim has previously been paid and the records do not indicate a second unit should be paid.  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.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has asserted that the claim has previously been paid. However, no documentation of this previous payment was returned to us and we cannot verify the Plan's argument. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scan of the abdomen and pelvis (74176) provided on September 14, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an upper partial denture (D5213).  You asked the Plan to pre-approve an upper partial denture. You say that the service is necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 5 years.  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, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an upper partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on November 2, 2020. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Metanx Capsule.  You asked the Plan to pre-approve Metanx. You say that the enrollee has been stable on this drug for several months. You also say that it is necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Metanx Capsule.   Benefits for Metanx may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for an epidural injection provided on October 4, 2021.  You asked the Plan to pay for epidural injection. You say that this service has been found effective and Medicare does not have a diagnosis code limitation for this procedure. The Plan denied your request. The Plan says the denial of payment for this service is correct, because no medical records have been submitted to support the billing of this procedure code.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. You have not submitted any records to support the billing of this service. The Plan requested records, but they were not submitted. Without records, you have not furnished sufficient information to support the payment of this claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of epidural injection have not been met. Therefore, we decided that the Plan does not have to pay for an epidural injection provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Baroreflex activation device.  You asked the Plan to pre-approve the Baroreflex activation device. You say that the patient's heart failure is progressively worsening that they qualify for the device. You say that the patient is an ideal candidate, and the implant is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental and unproven.  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 the Baroreflex activation device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in this patient's clinical management.    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 Baroreflex activation device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Baroreflex activation device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown re-bonding (D2920) provided by an opt-out provider on June 8, 2021, to July 8, 2021.  You asked the Plan to pay for a crown re-bonding. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the provider 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 a crown re-bonding (D2920) provided by an opt-out provider on June 8, 2021, to July 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy with lesion removal performed on October 14, 2021.  You asked the Plan to waive the copayment for the colonoscopy. You say that the procedure was only a screening and the polyp removal was necessary. 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 $225 copayment for each ambulatory surgical center visit.   You have been asked to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the Colorectal Cancer Screening 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 colonoscopy with lesion removal performed on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization.  You asked the Plan to pre-approve psychiatric hospitalization. You say that the requested admission is medically necessary. The Plan denied your request. The Plan says the requested admission is not medically necessary. The Plan also says Medicare does not pay for hospital services that are paid for by a state government.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.    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 psychiatric hospitalization. Our reviewer says that the requested inpatient psychiatric admission is not medically necessary. Our physician reviewer found the records provided indicate that it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others. The reviewer found that the enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. Therefore, the reviewer found that the requested admission is not medically necessary  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychiatric hospitalization have not been met. Specifically, the file shows that it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit (99213) provided on November 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that your provider told you that you need a second opinion. You also say you are a cancer patient and could not wait two years for a specific cancer test. The Plan denied your request. The Plan says this provider is not contracted by the Plan and there are 8 contracted providers in this specialty in the member's hometown. The Plan also says that the member would need to obtain authorization from the Plan prior to seeking 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 a specialist office visit (99213) provided on November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the colonoscopy with lesion removal (45385), the moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports (G0500), and the moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, each additional 15 minutes (99153) rendered by the out-of-network (OON) provider on September 22, 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 were rendered by an out of network provider, without prior authorization.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The  provider in this case 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 colonoscopy with lesion removal (45385), the moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports (G0500), and the moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, each additional 15 minutes (99153) rendered by the out-of-network (OON) provider on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tub transfer bench.  You asked the Plan to pre-approve a tub transfer bench. You say that you had your left leg amputated above the knee. You say that you need the requested item for hygienic reasons. You say that standing is not an option without a walker and standing with one leg in the shower is unsafe and impossible to do. The Plan denied your request. The Plan says the requested item does not meet the definition of durable medical equipment.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub transfer bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for general anesthesia (D9223), and a benign cyst removal (D7450) provided by a participating provider on August 30, 2021.  You asked the Plan to pay for general anesthesia and a benign cyst removal. You say that you needed this cyst removed to stop the bleeding. The Plan denied your request. The Plan says the services that were provided are not covered dental benefits.  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 general anesthesia (D9223), and a benign cyst removal (D7450) provided by a participating provider on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound (76705) provided on September 27, 2021.  You asked the Plan to pay for code 76705. 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 76705 is a column II code to column I code 93976. 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 ultrasound (76705) provided on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76705) provided September 23, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not separately payable.  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 76705 has a bundled relationship with code 93976. 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 radiology services (76705) provided September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for  office services and imaging services provided by a chiropractor on September 20, 2021, and September 21, 2021.  You asked the Plan to pay for  these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says any services provided by a chiropractor that are not manual manipulation of the spine are not covered.  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 are issue were not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for  office services and imaging services provided by a chiropractor on September 20, 2021, and September 21, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to reduce the cost-share for the specialist office visits. We decided that the Plan does not have to waive the cost-share for the specialist office visits.   You asked the Plan to waive the cost-share for the specialist office visits. You say that the policy information book says the services are covered. The Plan says that you have been asked to pay the correct cost-sharing amount.  We decided that the Plan has to reduce the cost-share for the specialist office visits.   The record shows the address associated with the provider's national provider identity (NPI) and the address on the claim show the services were rendered at an office.  The Plan says you must pay a total of $89.13 for the specialist office visits. Based on the Plan contract, however, you cannot be asked to pay more than a $15 copayment per date of service for the specialist office visits. Therefore, we decided the Plan has to reduce the cost-share from $89.13 to a $15 copayment per date of service.  We also decided that the Plan does not have to waive the cost-share for the specialist office visits.  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 $15 copayment per visit for an out-of-network specialist. Therefore, we decided that the Plan does not have to waive the cost-share for the specialist office visits.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 9, 2021, to August 20, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $295 copayment per day for days 1-6 of Inpatient hospital care.        You have been asked to pay a $1,770 copayment for six days of inpatient hospital care ($295 x 6 = $1,770). 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 inpatient hospital care provided from August 9, 2021, to August 20, 2021.