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

 We decided that the Plan does not have to pay for the neurological testing services provided on March 27, 2020.  You asked the Plan to pay for the neurological testing services. You say that you recently became aware some claims had not been filed timely and would like this specific claim reprocessed. The Plan denied your request. The Plan says this is past the Medicare-allowed 12 month timeframe for filing claims.  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 neurological testing services was not filed until June 21, 2021. 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 the neurological testing services provided on March 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Imfinzi (Durvalumab) injection for the enrollee.  You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the records did not show that you are responding positively to therapy.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of lung adenocarcinoma. The record indicates that a computed tomography (CT) scan in December 2021 has demonstrated disease progression while receiving consolidation therapy with the requested drug. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied.  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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an Imfinzi (Durvalumab) injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenetic testing provided on July 27, 2021.  You asked the Plan to pay for the testing services. You say that the testing helps assess the efficacy of the treatment plan. The Plan denied your request. The Plan says the test should not be unbundled to separate codes.  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 looked at the file and the rules. The records show that the gene panel provided was billed using multiple CPT codes. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection of the small joint or bursa (20600, G0463) provided on September 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to waive the copayment for arthrocentesis, aspiration and/or injection of the small joint or bursa. You say that you thought it was covered with the Plan. You also say that you had x-rays done this year and never received a bill. You also say you are on a fixed income and cannot afford these charges. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $210 copayment for each Medicare-covered outpatient hospital services for Outpatient Hospital Services.   You have been asked to pay a $210 copayment for arthrocentesis, aspiration and/or injection of the small joint or bursa. Arthrocentesis, aspiration and/or injection of the small joint or bursa falls within the Outpatient Hospital Services benefit category. This is a covered service, however, there is a copayment applied to it. 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 arthrocentesis, aspiration and/or injection of the small joint or bursa (20600, G0463) provided on September 30, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the enrollee requires skilled rehabilitation services for her multiple conditions leading to hospital admission. The Plan denied your request. The Plan says that the services the enrollee requires can safely be received at a different setting.  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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies (A4595x30) provided on June 12, 2021. You asked the Plan to pay for the TENS supplies. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says the proof of delivery supplied does not match the date of service on the claim.
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a physician order and proof of delivery. The rules also state that separate allowance will be made for replacement supplies when they are reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS supplies have not been met. Specifically, the file does not include a valid proof of delivery or medical records for the billed date of service. Additionally, this request exceeds the maximum units allowed per month. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies (A4595x30) provided on June 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable and near baseline and should only require short-term additional acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed and when her chronic condition treatment needs are required.   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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on May 30, 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 code of "B". A status code of B means that payment for this service 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 May 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient office visit (99202) provided on July 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an outpatient office visit. You say that the patient came to your outpatient office at the facility; therefore, these services are rendered in an outpatient office setting. You also say you were referred by the nursing facility to see the patient. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and a valid authorization was not obtained prior to the services being rendered. The Plan also says that it was determined that the services were not urgent or emergent.  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 an outpatient office visit (99202) provided on July 8, 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 coded as 99053 provided on June 10, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says you have not billed this claim as required by Medicare coding regulations.  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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.  We looked at the file and Medicare rules. In this case, code 99053 has a Status Code of "B" under the Physician Fee Schedule indicating it is a Bundled Code. This means that payment for this service is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99053 provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a folding wheeled walker (E0143) with seat attachment (E0156) provided on September 7, 2021.  You asked the Plan to pay for a folding wheeled walker with seat attachment. You say that the items at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the ordering provider is the owner of the durable medical equipment supplier.  The Plan must follow Medicare rules. Medicare rules say that a physician may not refer a Medicare patient for durable medical equipment and supplies to an entity with which the physician (or an immediate family member of the physician) has a financial relationship.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a folding wheeled walker with seat attachment have not been met.  Specifically, the case record shows that the referring physician in this case has a financial relationship with the entity supplying the items at issue. Therefore, we decided that the Plan does not have to pay for a folding wheeled walker (E0143) with seat attachment (E0156) provided on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder testing rendered on June 18, 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 are not covered.  The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.  We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the myocardial perfusion imaging provided on June 25, 2021.  You asked the Plan to reduce the copayment for the myocardial perfusion imaging. You say that you were told there would be a $105 copayment. You say you would not have had the procedure if you knew it was a $350 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for nuclear medicine services at an in-network outpatient hospital.   You have been asked to pay a $350 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the myocardial perfusion imaging is considered a nuclear medicine service.   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 reduce the copayment for the myocardial perfusion imaging provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on August 17, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the provider is not contracted, there was no prior authorization request, there was no primary care physician referral, there was no medical emergency, there is a contracted provider in the member's hometown.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. 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 hearing aids. We found no exception that would require the Plan to pay for the hearing aids. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), three localized deliveries of antimicrobial agents (D4381 x3), and four gingival irrigations (D4921 x4) provided on July 27, 2021.  You asked the Plan to pay for the topical application of fluoride varnish, localized deliveries of antimicrobial agents, and gingival irrigations. You say that you would like to be reimbursed the full amount for these services. The Plan denied your request. The Plan says these services are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), three localized deliveries of antimicrobial agents (D4381 x3), and four gingival irrigations (D4921 x4) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine (E0601) and battery (E1399), purchased on April 1, 2021.  You asked the Plan to pay for the CPAP machine and batteries. You say that the items were medically necessary. The Plan denied your request. The Plan says you obtained these items through a provider that is not enrolled in 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 continuous positive airway pressure (CPAP) machine (E0601) and battery (E1399), purchased on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 28, 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 are not covered.  The Plan must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with previous negative prostate biopsy who are being considered for repeat biopsy.  We looked at the file and Medicare rules. The records do not contain results of a prior prostate biopsy. 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 ConfirmMDx testing rendered on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia for percutaneous image guided procedures on the spine and spinal cord coded 01936 provided on June 30, 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 are not payable 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, the CPT Code Manual definition of code 01936 is anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic.    We find that CPT code 01936 is not supported in the medical record. Specifically, this anesthesia code is not the correct code to report with pain management injections when less deep sedation was given to the enrollee. The documentation shows that this code was billed with codes 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscles) and 62321 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)). The documentation shows that general anesthesia was performed for a pain management procedure; however, Propofol or Diprivan was not used. Therefore, deep sedation was not achieved. 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 for percutaneous image guided procedures on the spine and spinal cord coded 01936 provided on June 30, 2021.