Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services received on June 2, 2021.
You asked the Plan to waive the copayment for a physical therapy service. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment applied was 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 $10 copayment for each Medicare-covered outpatient rehabilitation service visit. The Plan has agreed to reimburse you $53.38 for this physical therapy service. You have been asked to pay a $10 copayment for a physical therapy service. Physical therapy falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy services received on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on January 3, 2021 by a provider who is not a certified Medicare supplier.

You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration because there should only be a 20% coinsurance for the supplied equipment. The Plan denied your request. The Plan says this provider is not a Medicare certified provider.

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 Medicare certified durable medical equipment supplier. 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 durable medical equipment provided on January 3, 2021 by a provider who is not a certified Medicare supplier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on November 30, 2020.
You asked the Plan to pay for the provided service. You say that medical records prove medical necessity. The Plan denied your request. The Plan says coverage criteria have not been met.
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 the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, and had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the provided service have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies coded as 95908 provided December 14, 2020.
You asked the Plan to pay for the nerve conduction studies. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says code 95908 is not supported in the medical records.
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 95908 is nerve conduction studies; 3-4 studies 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 nerve conduction studies.
Our reviewer says that the documentation does not support the code was performed as billed. Our reviewer found that the enrollee is a 78-year-old man with lumbar spine degenerative disc disease with L4-5 spondylolisthesis, who underwent a surgical procedure. Intraoperative neurophysiologic monitoring was performed. Stimulation of the pedicle screws at the L4 and L5 pedicle levels revealed motor responses at thresholds consistent with intact pedicles that were satisfactory to the surgeon. The documentation does not support the performance of 3 - 4 nerve conduction studies. 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 nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded as 95908 provided December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical fusion.

You asked the Plan to pre-approve cervical fusion. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 cervical fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for multilevel laminectomy and fusion are not met. There is no severe stenosis or cord compression. There is no instability. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical fusion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on May 21, 2020.
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 billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered on May 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy provided on February 24, 2021.
You asked the Plan to waive the copayment for a biopsy. You say that you were never told about the charge upfront. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $275 copayment for each in-network Medicare-covered outpatient surgery at an ambulatory surgical center.
You have been asked to pay a $275 copayment for a biopsy. Biopsies fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers, 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 biopsy provided on February 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services provided from December 23, 2019, through December 27, 2019.

You asked the Plan to pay for the home health aide services. You say that these services should be paid. The Plan denied your request. The Plan says this provider is not a Medicare enrolled home health agency.

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 home health aide services provided from December 23, 2019, through December 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing visits.

You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says the currently
approved visits appear to be sufficient to meet your needs.

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 additional visits. Our physician
reviewer found that you do not have documented skilled nursing needs (i.e., intravenous medications, complex
wound care, new ostomy). As such, the requested, ongoing skilled nursing services are not shown to be
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 additional visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional home health skilled nursing visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a new plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81162, 81201, 81298, 81317, and 81403 provided on November 30, 2020.
You asked the Plan to pay for the laboratory 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. We find that CPT codes 81162, 81201, 81298, 81317, and 81403 are not supported in the medical record. Specifically, the documentation shows that molecular pathology testing was rendered. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. The documentation does not support that only one code was submitted for the panel provided.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81162, 81201, 81298, 81317, and 81403 provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot/cold packs (97010) mechanical traction (97012) electrical stimulation (unattended) (97014) provided February 24, 2020 to March 20, 2020.

You asked the Plan to pay for the chiropractic services. You say that the doctors are upset at you. It is not your fault. Please resubmit the claims and pay them. The Plan denied your request. The Plan says these services are not covered when rendered 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. Therefore, we decided that the Plan does not have to pay for the hot/cold packs (97010) mechanical traction (97012) electrical stimulation (unattended) (97014) provided February 24, 2020 to March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removable unilateral partial denture (D5282) provided on January 6, 2021.

You asked the Plan to pay for the dental service. You say that you had to get a tooth pulled in late 2020. You say that this was covered by your insurance. You say that you do not understand why your insurance is not paying for the replacement of your tooth. You say that you have $1,000 for dental services. You also say that you do not understand why you have to pay $701 to fill in the gap. The Plan denied your request. The Plan says removable unilateral partial denture is not listed as a covered dental service.

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 removable unilateral partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removable unilateral partial denture (D5282) provided on January 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation services (A0430) provided on October 27, 2020, to return the enrollee to the United States from another country.

You asked the Plan to pay for the air transportation. You say that these services were medically necessary. The Plan denied your request. The Plan says the rules for coverage of air ambulance services were not followed and criteria for coverage was not met.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the enrollee is covered. Transportation back to the United States from another country is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air transportation have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation services (A0430) provided on October 27, 2020, to return the enrollee to the United States from another country.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health certifications (G0180) provided on March 27, 2021.
You asked the Plan to pay for home health certifications. You say that this is supported in the records. The Plan denied your request. The Plan says the billed units exceed MUE.
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 G0180 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of home health certifications have not been met. Therefore, we decided that the Plan does not have to pay for home health certifications (G0180) provided on March 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received by an opt out provider on April 19, 2021.

You asked the Plan to pay for the dental services. You say that you received reimbursement from the last time you saw this provider. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services received by an opt out provider on April 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) annual wellness visit
(G0439) provided on January 28, 2021.

You asked the Plan to pay for the office visit. You say that the enrollee was not covered under hospice on the
date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for
payment of all Medicare covered services related or unrelated to the member's terminal condition until the first
day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on January 12, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the outpatient office
visit (99214) annual wellness visit (G0439) provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the tax (D9985) applied to the dental services
provided on June 21, 2021.
You asked the Plan to reimburse you for tax. You say that this is not a sales tax; it is a health care tax applied
by your state. You feel this cost should be reimbursed to you by the Plan. The Plan denied your request. The
Plan says Medicare and the Plan do not pay tax for medical items and services. As the patient, you are not
legally obligated to pay this tax/surcharge.
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. Medicare does not reimburse
separately for sales tax. The Plan also follows this rule.
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 reimburse you for
the tax (D9985) applied to the dental services provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 1, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 office visit provided on December 1, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received by an opt out provider on June 22, 2021.

You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services received by an opt out provider on June 22, 2021.