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

We decided the Plan has to hold you harmless for a computed tomography scan with calcium scoring provided on June 3, 2021 (minus any applicable copayment).
You asked the Plan to pay for a computed tomography scan with calcium scoring provided on June 3, 2021. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says that a computed tomography scan with calcium scoring is not covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for a computed tomography scan with calcium scoring provided on June 3, 2021 by a contract provider. The file does not show that the Plan provided notice that a computed tomography scan with calcium scoring provided on June 3, 2021 would not be covered. Under Medicare rules, this means a computed tomography scan with calcium scoring provided on June 3, 2021 is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a computed tomography scan with calcium scoring provided on June 3, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health physical therapy visits.
You asked the Plan to pre-approve 8 home health physical therapy visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 8 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented; home health physical therapy needs. The enrollee appears to have reached a plateau in function. As such, ongoing, home health physical therapy services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health physical therapy visits
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the second unit of lab services represented by code 82746.
You asked the Plan to pay for the second unit of code 82746. You say that these lab services were medically necessary for this patient. The Plan denied your request. The Plan says you have billed for two units of code 82746 on this date of service, and only one is covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 82746 is 1. The MAI value for this code is 2. You billed two units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 82746 have not been met. Therefore, we decided that the Plan does not have to pay for the second unit of lab services represented by code 82746
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor to be provided by an outof-
network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you will not use test strips. The Plan denied
your request. The Plan says there are in-network providers who can supply continuous glucose monitors.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a
continuous glucose monitor to be provided by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Chemotherapy administration (96420), Angiography (75726), and Angiography each additional vessel (75774) provided on April 30, 2021.
You asked the Plan to pay for codes 96420, 75726, and 75774. 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 enrollee received services (96420) while in an outpatient hospital setting. Per Medicare payment guidelines, code 96420 has a PC/TC indicator of 5 and payment may not be made for this code when provided to patients in an outpatient hospital setting. Furthermore, providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 75726 and 75774 are column II codes to column I code 37243. 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 Chemotherapy administration (96420), Angiography (75726), and Angiography each additional vessel (75774) provided on April 30, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services you received in an outpatient hospital facility on July 21, 2021.
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you were incorrectly charged a copayment for outpatient surgery. You said that the services you had on this date were pre-admission testing services, not surgery. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $350 copayment for the outpatient hospital services. We looked at the billing records to determine what type of services you received on July 21, 2021. While you did receive some testing services during this visit, you also received a vascular access procedure coded with procedure code 36600. Medicare considers this procedure code to be a surgery code.
That is why the outpatient surgery copayment applies to the services you had on this date. 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 services you received in an outpatient hospital facility on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (code D0274) and the periapical
radiographic image (code D0220) you received on August 31, 2021.
You asked the Plan to pay for the dental x-rays. You say that you thought the dentist had contacted your
previous dentist to get copies of your x-rays. You stated that you did not request the x-rays you had on August
31, 2021, and you were unaware that these were occurring. The Plan denied your request. The Plan says the
only dental x-rays covered under your plan are complete series intraoral x-rays (code D0210) and panoramic xrays
(code D0330). The specific dental x-rays you received are not covered by your plan for any reason.
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 services you received are not
among those covered under this benefit. These services are not covered for any reason. Therefore, we decided
that the Plan does not have to pay for the bitewing x-rays (code D0274) and the periapical radiographic image
(code D0220) you received on August 31, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the podiatry services provided on August 19, 2021.
You asked the Plan to pay for the podiatry services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the podiatry services by a contract provider. The Plan covers podiatry services beyond Medicare coverage, such as routine foot care. The file does not show that the plan provided notice to the enrollee that the podiatry services would not be covered. Under Medicare rules, this means the podiatry services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the podiatry services provided on August 19, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Noninvasive ear or pulse oximetry (94761) and the Automatic blood pressure monitor (A4670) provided on September 20, 2019.
You asked the Plan to pay for codes 94761 and A4670. 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.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 94761 is not supported in the medical record. Specifically, this code has a status indicator of N. Payment is packaged into payment for a separately paid service. Medicare rules also say that codes A4650 - A4927 and E1510 - E1702 may be used only for supplies and equipment relating to home dialysis. The CPT code for the blood pressure monitor at issue, A4670, is in the range of codes A4650 - A4927 that are only for supplies and equipment relating to home dialysis. The record shows this item was not provided in relation to home dialysis. Therefore, we decided that the Plan does not have to pay for the Noninvasive ear or pulse oximetry (94761) and the Automatic blood pressure monitor (A4670) provided on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided on May 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chemotherapy services 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 chemotherapy services provided on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. 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.
The Plan follows Medicare rules. The rules state that claims for E0675 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim.
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for visits with a pain management specialist you had from February 19, 2021, to August 11, 2021.
You asked the Plan to waive the copayments for the pain management visits. You say that when you had a different plan, you did not have a copayment for these visits. You feel as though this doctor should be treated as your primary care doctor and you should not have to pay a copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for visits with a specialist.
You have been asked to pay a $40 copayment per visit for the pain management visits. The pain management visits fall within the visits with a specialist 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 copayments for visits with a pain management specialist you had from February 19, 2021, to August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on April 12, 2021.
You asked the Plan to pay for code 99309. 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 99309 is a column II code to column I code 90832. 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 subsequent nursing facility care (99309) provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiology office visit provided on May 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON cardiology visit. You say that there was no authorization requested because this is an office visit that does not require authorization. You feel that the services were medically necessary and should be paid. The Plan denied your request. The Plan says the services were not emergent in nature and were provided OON without authorization. This is not covered by the Plan.
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 cardiology office visit provided on May 3, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. You say that it is painful to prick yourself multiple times a day. The Plan denied your request. The Plan says the device is not reasonable and necessary at this time.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services 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 physician services provided on April 13, 2021 by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on January 20, 2020.
You asked the Plan to pay for the therapy 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 the services of a PT shall not be billed as services
incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications
of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and
not a licensed therapist. As such, PT services cannot be paid incident to this provider's professional services.
Therefore, we decided that the Plan does not have to pay for the therapy services provided on January 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on July 11, 2020.
You asked the Plan to pay for the medical services. You say that due to the COVID-19 pandemic, claim filing timeframes have been lifted. The Plan denied your request. The Plan says you did not file this claim timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the medical services was not filed until September 2, 2021. According to Medicare rules, there were some flexibilities regarding timely filing of claims for services rendered between
March 1, 2020, and May 5, 2021. However, all services rendered after May 5, 2021, are subject to the normal 12-month claim filing deadline. The services at issue in this appeal occurred after the May 5, 2021, cutoff. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for medical services provided on July 11, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2021.
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.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 12, 2021