Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) (CPT code G0453) provided to the enrollee on June 10, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says that the medical records submitted indicate this procedure was performed in an on-campus outpatient hospital (place of service code 22). The Plan states the claim form indicates a different place of service, specifically an Inpatient Hospital (place of service code 21). The Plan states the Place of Service (POS) billed must match the place of service where the face-to-face procedure took place; therefore, the billed service cannot be verified.  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 other codes on the claim were processed and paid with the same place of service as the code being denied. Therefore, the denial is not substantiated. Therefore, we decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) (CPT code G0453) provided to the enrollee on June 10, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on March 22, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were on pain medication until they were able to break up the stone. You also say that you cannot see why this is not covered. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare.  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 pay for the self-administered drugs provided on March 22, 2021.   Benefits for the self-administered drugs 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for PET scan provided on August 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the PET scan. You say that the service was medically necessary. 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the PET scan provided on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 6, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the paramedics said there was no need for the enrollee to be transported to the hospital due to being a health risk during the Coronavirus pandemic and the hospital would not be able to do anything for her. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, and then there is no Medicare-covered service.  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 March 6, 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 the ambulance response and treatment with no transport (A0998) provided on March 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on July 4, 2021.  You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has denied correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.  We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on July 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.   
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF admission is not medically necessary based on lack of medical complexity and with no rehabilitation nursing needs and inability to tolerate therapies. Documentation does not support the necessity for admission to IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room services provided on August 8, 2021.  You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for Emergency care.   We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on August 8, 2021. You have been asked to pay a $120 copayment for the emergency room services. The emergency room services fall within the Emergency 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 the emergency room services provided on August 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture provided on August 10, 2021.  You asked the Plan to pay for acupuncture. The Plan denied your request. The Plan says acupuncture is only covered for chronic back pain.   The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic back pain. Therefore, we decided that the Plan does not have to pay for acupuncture provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on February 11, 2021.  You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not support the Place of Service (POS) code billed on this claim.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for out of network services provided to the enrollee on July 31, 2021.  You asked the Plan to pay for these services. 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 must 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 services provided to the enrollee on July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenetics (PGx) testing rendered on March 13, 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 were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when specific criteria are met.  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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a history of ampullary adenocarcinoma, treated by pancreaticoduodenectomy in 2004. The enrollee has had a recurrence, which has been deemed unresectable. The Medicare rules state that once the putative therapeutic agents are selected, and those agents are known to have gene-drug interactions as identified above, then a PGx test may be considered reasonable and necessary when the result of that test is necessary for the physician's decision-making process regarding safely administering or dosing the drug. PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular diagnosis. Unless the record reflects that the treating clinician has already considered non-genetic factors to make a preliminary drug selection, PGx testing is not considered reasonable and necessary. The documentation does not support that the testing was reasonable or medically necessary for the enrollee.  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 pay for the pharmacogenetics (PGx) testing rendered on March 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite, three surfaces on tooth #9 (D2332) and a resin-based composite, four or more surfaces on tooth #10 (D2335) provided on August 12, 2021.  
You asked the Plan to pay for a resin-based composite, three surfaces and a resin-based composite, four or more surfaces. You say that you were not aware that you would be covered for only 2 fillings for the year. You do not remember receiving a booklet with this information. You also say that you have cancelled your remaining appointment with the provider as you cannot afford the charges and would not have had the work done had you known you were only covered for 2 fillings. The Plan denied your request. The Plan says the frequency limitation has been exceeded.    
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 a resin-based composite, three surfaces and a resin-based composite, four or more surfaces twice per calendar year.   We looked at the file and Medicare rules. The EOC confirms that you receive 2 resin-based composites per calendar year. The records show you received a resin-based composite on tooth #7 on July 27, 2021 and you received a resin-based composite on tooth #8 on August 12, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite, three surfaces and a resin-based composite, four or more surfaces have not been met. Therefore, we decided that the Plan does not have to pay for a resin-based composite, three surfaces on tooth #9 (D2332) and a resin-based composite, four or more surfaces on tooth #10 (D2335) provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the power mobility device provided on August 4, 2021.  You asked the Plan to pay for the power mobility device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the durable medical equipment provider is not enrolled in the Medicare program.  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 power mobility device provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound care supplies provided on September 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the wound care supplies provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services (99053) provided on June 6, 2021.  You asked the Plan to pay for code 99053. 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. Code 99053 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the medical services (99053) provided on June 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the Magnetic resonance imaging (MRI) and the Gadobutrol injection provided on May 26, 2021.  You asked the Plan to waive the cost share for the MRI and the Gadobutrol injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an MRI and a Gadobutrol injection on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.  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 $155 copayment for Medicare-covered radiological diagnostic services and a 20% coinsurance for each Medicare-covered medical supply.   We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an MRI and a Gadobutrol injection on May 26, 2021. You have been asked to pay a $155 copayment for the MRI and a 20% coinsurance for the chemical agent used for the diagnostic test (Gadobutrol injection). The MRI and the Gadobutrol injection fall within the Outpatient diagnostic tests 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 cost share for the Magnetic resonance imaging (MRI) and the Gadobutrol injection provided on May 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 7, 2021 by an out-of-network (OON) provider.    You asked the Plan to pay for the subsequent nursing facility care. You say that you have re-applied for in-network status, but the Plan denied without cause. You also say that you would like this claim to be reconsidered for payment due to the fact the enrollee resides in a nursing home and your provider provides acute visits to the nursing home. The Plan denied your request. The Plan says this service was rendered by a provider who is not under contract with the Plan. The Plan also says that this service was not approved in compliance with the Plan's authorization procedure.  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 subsequent nursing facility care (99308) provided on July 7, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the cataract surgery (66984) and the after cataract laser surgery (66821) provided from March 9, 2020, through July 2, 2020.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 a $40 copayment per visit may apply for Medicare-covered physician services, for outpatient surgery.   You have been asked to pay $160 ($40 copayment x 4 outpatient surgeries) for the Medicare-covered physician services 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 copayments for the cataract surgery (66984) and the after cataract laser surgery (66821) provided from March 9, 2020, through July 2, 2020.