Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the peripheral nerve block rendered on August 17, 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 64450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 64450 (peripheral nerve block) and 14040 (adjacent tissue
transfer). Code 64450 is a column II code with a modifier indicator of 1 when billed with column I code 14040.
Code 64450 was not billed with an appropriate modifier to allow for separate payment. The -59 modifier is not
supported as a separate and distinct service. Therefore, we decided that the Plan does not have to pay for the
peripheral nerve block rendered on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on
September 16, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you never seen the
physician at the office visit. The Plan denied your request. The Plan says medical records provided show
services rendered by physician and proper copayment 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 a $30
copayment for office visits to specialists at a facility-operated professional clinic.
You have been asked to pay a $30 copayment for the specialist office visit. A specialist office visit falls within
the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist office visit provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX Melanoma test provided to the enrollee on
July 1, 2021.
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your
request. The Plan says this is not the standard of care within the medical community.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the difficulty in embracing gene expression profiling as an independent predictor of outcome is
illustrated by the inconsistency of results across studies aimed at defining the most predictive gene sets for
melanoma. The lack of overlap in gene signatures identified as prognostic for melanoma is likely due
substantial differences in study design and methodology. Furthermore, a high-risk decision Dx melanoma does
not translate into a therapeutic intervention as adjuvant immunotherapy with a PD1 inhibiter or yervoy is
reserved for node positive stage IIB- III disease. Page ME-9 and ME-10 defines follow up for stage IA-IIA and
IIB-IV respectively. Follow-up for Stage IIB-IV includes imaging every 3-12 months, whereas imaging not
required for Stage Ia-IIA. Follow up is not dictated by Decision Dx Melanoma risk profile. Decision Dx
Melanoma is experimental and investigational as treatment and surveillance.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the DecisionDX Melanoma test provided to the enrollee on July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for room and board services from August 13, 2021, through
August 31, 2021.
You asked the Plan to pay for room and board services. You say that you did not feel well enough to go home
after the discharge date, and you did not feel safe to go home due to plumbing repairs. The Plan denied your
request. The Plan says room and board is not a covered benefit. Also, custodial care provided in a nursing
home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care is
not covered.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of room and board services have not been met. Specifically, we find that the services at issue in this
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for room and
board services provided from August 13, 2021, through August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
bitewing - single radiographic image (D0270) provided September 20, 2021.
You asked the Plan to pay for the limited oral exam and bitewing x-ray. You say that this was a necessary
exam, and it is reasonable that it should be covered. The Plan denied your request. The Plan says you have
exceeded the frequency limits for these services.
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 the limited
oral exam and bitewing x-ray once per plan year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a bitewing x-ray and
limited oral exam were previously covered on March 25, 2021. Based on this information, we decided that the
Plan's frequency limit for coverage of the limited oral exam and bitewing x-ray has been exceeded. Therefore,
we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
bitewing - single radiographic image (D0270) provided September 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient lift (E0630) and delivery (A9901), provided on
June 15, 2021.
You asked the Plan to pay for the patient lift and delivery. You say that you did not know this provider was not
enrolled in Medicare. The Plan denied your request. The Plan says the provider is not certified with Medicare.
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 patient lift (E0630) and delivery
(A9901), provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 12, 2021 by an out-of-
network (OON) provider.
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 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 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 drug testing provided on May 12, 2021 by an
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care and ambulance
services provided from August 10, 2021, through August 15, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care and ambulance services. You say
that you should not have to pay. The Plan denied your request. The Plan says the cost share was applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 ambulance copay for each one-way trip and a $275 inpatient hospital care copayment for each
day one through five.
The enrollee has been asked to pay a $250 ambulance copay for each one-way trip and a $275 inpatient
hospital care copayment for each day one through five. These services fall within the ambulance services and
inpatient hospital care benefit category. 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 care and ambulance services provided from August 10, 2021, through August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on September 9, 2021, by an
OON provider.
You asked the Plan to pay for the laboratory work. You say that your provider sent you to this laboratory and
you say you do not have the money to pay for the service. The Plan denied your request. The Plan says no prior
authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. 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 laboratory work provided on September 9,
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Selective Internal Radiation Therapy (SIRT).

You asked the Plan to pre-approve SIRT. You say that this service is medically necessary. The Plan denied your request. The Plan says that this request cannot be approved is because guidelines do not support the routine use of the requested type of treatment for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 SIRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found systemic therapy is the standard treatment option for the enrollee's condition. Radioembolization is not outside the generally accepted professional medical standards as being safe and effective. The treatment at issue is considered medically necessary for the enrollee's condition when other options are not available. The enrollee's condition is imminently life-threatening and the treatment at issue would be within the accepted standard of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SIRT have been met. Therefore, we decided that the Plan has to pre-approve Selective Internal Radiation Therapy (SIRT).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on July 2,
2021.

You asked the Plan to pay for the anesthesia services. 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 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, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status
indicator of "B". A status indicator of B means that payment for these services is always bundled into payment
for other services not specified and no separate payment can be made. Based on this information, we decided
that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the
Plan does not have to pay for the anesthesia services coded 99100 provided on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from August 9, 2021,
through August 17, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services was not medically necessary.
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 pay for continuation of SNF services. Our reviewer
says that daily skilled services were not medically necessary. Our physician reviewer found based on the
medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the
specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and
effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely
and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required.
As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing
facility setting. Services in the nursing facility appear custodial in this case from August 9, 2021, through
August 17, 2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided from August 9, 2021, through
August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation discharge day management services (99217)
provided on August 21, 2021.
You asked the Plan to pay for the observation discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the qualifying
initial or subsequent Observation care codes have not been 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, the CPT Code Manual definition of code 99217 is observation care discharge day management
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital
"observation status" if the discharge is on other than the initial date of "observation status." To report services
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236
as appropriate.]).
We find that CPT code 99217 is not supported in the record. Specifically, the documentation submitted does
not indicate that the qualifying observation care codes have been billed. Based on this information, we decided
that Medicare rules for coverage of the observation discharge day management services have not been met.
Therefore, we decided that the Plan does not have to pay for the observation discharge day management
services (99217) provided on August 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
non-emergency transport (A0428), and ground mileage (A0425) provided August 26, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance services and ground mileage.
You say that you were told that medical charges related to coronavirus (COVID-19) would be waived. The
Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for each Medicare-covered trip (one-way) by ambulance.
You have been asked to pay a $300 copayment for the non-emergency ambulance services and ground mileage.
The non-emergency ambulance services and ground mileage falls within the Ambulance services benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-
emergency transport (A0428), and ground mileage (A0425) provided August 26, 2021.
Your complaint about potentially being provided misinformation from the Plan is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 26, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a Triiodothyronine T3 assay, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Osteogenesis stimulator (E0760)
provided on May 14, 2021.
You asked the Plan to waive the copayment for the Osteogenesis stimulator. You say that you should not have
to pay for this item. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for the Osteogenesis stimulator. This item 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 copayment for the Osteogenesis stimulator (E0760) provided on May 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on July
22, 2020, to November 25, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $210 copay for each one-way trip for ambulance services.
The enrollee has been asked to pay a $210 copay for each one-way trip for the ambulance services. This service
falls within the ambulance services benefit category. 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 ambulance services provided on July 22, 2020, to November 25, 2020.