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

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 18, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on March 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound represented by code 76700-26 provided on April 24, 2021.
You asked the Plan to pay for code 76700-26. 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 76700-26 has a bundled relationship with code 93975 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound represented by code 76700-26 provided on April 24, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that it is necessary for the enrollee to upgrade from a group 2 power wheelchair to a group 3 power wheelchair. The Plan denied your request. The Plan says the criteria have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81291, 81405, 81406, 81407, 81408, 81479, 81439, 81401, 81404, 81403) provided August 20, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels.
We looked at the file and Medicare rules. The services at issue are not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81291, 81405, 81406, 81407, 81408, 81479, 81439, 81401, 81404, 81403) provided August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the ankle (73720).
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your request. The Plan says it is not clear how this will effect the enrollee's treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the submitted records do not include information regarding a trial and failure of recent, reasonable, and comprehensive conservative care measures. In addition, there is no documentation indicating how the updated imaging would change the course of treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the ankle (73720).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve open right gluteus medius repair with Arthrex dermal graft 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 open right gluteus medius repair with Arthrex dermal graft in the setting of gluteal tendinitis has 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. Arthrex dermal graft is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's 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 open right gluteus medius repair with Arthrex dermal graft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and injection services provided on December 21, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization was required but not 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 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 items/services. Therefore, we decided that the Plan does not have to pay for the office visit and injection services provided on December 21, 2020 by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided May 4, 2021.
You asked the Plan to pay for the ultrasound. 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 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76705) provided May 4, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiopulmonary resuscitation services provided on January 14, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code was billed with either an invalid or missing modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 92950 is cardiopulmonary resuscitation (eg, in cardiac arrest). This code was billed with modifier 51.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the services provided. Our reviewer found that modifier 51 is
used when multiple procedures, other than evaluation and management services, Physical Medicine and
Rehabilitation services, or provision of supplies, are performed at the same session by the same provider. In
this case, the record indicates that the enrollee arrived at the emergency department in cardiac arrest and
underwent cardiopulmonary resuscitation. The record indicates that this is the primary procedure. The use of
modifier -51 is incorrect. The elements of the coverage rule are it satisfied.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the cardiopulmonary resuscitation services provided on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says this service or item is considered to be experimental/investigational because it is not widely used and not generally accepted.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental. More research is needed to show safety and efficacy.
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on May 5, 2021.
You asked the Plan to waive the copayment for a medical eye exam. You say that this visit was for a routine annual eye exam. The Plan denied your request. The Plan says the copayment you are being charged 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 $35 copayment for Medicare-covered exams to diagnose and treat diseases of the eye and injuries of the eye, including treatment for age-related macular degeneration.
You have been asked to pay a $35 copayment for a medical eye exam. The records show that you had a medical eye exam with fundus photography and your diagnosis was Drusen macular degeneration and age-related nuclear cataract. The EOC confirms that $35 is the required copayment for this service. A medical eye exam falls within the vision care 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 medical eye exam (92014) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 3, 2020.
You asked the Plan to pay for the laboratory services. 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.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power operated vehicle and accessories.
You asked the Plan to pre-approve a group 2 power operated vehicle and accessories. You say that you would like a smaller wheelchair to be used in the community. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.
The file shows that your condition can be improved by a walker, cane or manual wheelchair. In addition, it does not appear that this device would be used in your home and is instead requested for use outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated vehicle and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the enrollee has not benefited from oral osteoporosis
medications. You also say that the enrollee needs to try another method. The Plan denied your request. The
Plan says the enrollee has not tried and failed treatment with one intravenous bisphosphonate therapy, such as
zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, zoledronic acid. The reviewer also found that there is no
documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that Prolia is not medically reasonable or necessary as the step therapy criteria has not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drug, zoledronic acid. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (97012, 98943, and 99214) provided from April 3, 2021 to April 26, 2021.
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services you received, codes 97012, 98943, and 99214 are not covered by Medicare or the Plan when billed by a chiropractor.
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. The codes denied on the claim are not payable when provided by a chiropractor. Therefore, we decided that the Plan does not have to
pay for the non-covered chiropractic services (97012, 98943, and 99214) provided from April 3, 2021 to April
26, 2021.
Your complaint about not being provided the correct information 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast ultrasound provided on June 30, 2021 by an outof-
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee had an abnormal mammogram. The
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 ultrasound 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 breast ultrasound provided on June 30, 2021 by an out-ofnetwork
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 22, 2020.
You asked the Plan to pay for the laboratory services. 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.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 22,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on February 26,
2021.
You asked the Plan to waive the copayment for lab tests. You say that these lab tests were done at your doctor's
office which has a $0 copayment with this plan. The Plan denied your request. The Plan says the copayment
amount you are being charged 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 $25
copayment for lab tests at all locations other than your doctor's office or independent lab locations. This
provider is an outpatient hospital facility, and not a doctor's office, therefore the $25 lab copayment applies to
this claim.
You have been asked to pay $25 copayment for lab tests. Lab tests fall 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 laboratory testing provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99358) provided December 2, 2020.
You asked the Plan to pay for physician services. You say that the services were medically necessary. The Plan
denied your request. The Plan says separate payment cannot be made for the billed code.
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 99358 has a bundled relationship with code 99310 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99358) provided December 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan represented by code 93976-26 and the
ultrasound represented by code 76705-26-59 provided on February 20, 2021.
You asked the Plan to pay for codes 93976-26 and 76705-26-59. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the documentation provided
does not support the services 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 93976 is Duplex scan of arterial inflow and venous
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study. We find that CPT
code 93976 is not supported in the medical record. Specifically, the medical records provided do not indicate
that the arterial inflow or venous outflow were evaluated. As the medical records do not support the billing of
code 93976, and since there is a conflict between codes 93976 and 76705, code 76705 with the use of modifier
-59 cannot be verified if Medicare payment criteria had been met. Based on this information, we decided that
Medicare rules for coverage of codes 93976-26 and 76705-26-59 have not been met. Therefore, we decided
that the Plan does not have to pay for the duplex scan represented by code 93976-26 and the ultrasound
represented by code 76705-26-59 provided on February 20, 2021.