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

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 25, 2021 billed under code 99053.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan per the Medicare billing guidelines, code 99053 has a status indicator of 'B'. The billing guidelines states that status code B = Bundled Code. This means payment for covered services are always bundled into payment for other services not specified and no separate payment is made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, we have confirmed that code 99053 was billed incorrectly. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 25, 2021 billed under code 99053.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from June 18, 2021, to June 22, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this copayment is too high. 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 per day for days 1-5 for inpatient hospital services. Records show that you were in the hospital for 4 days. You were charged a $350 copayment per day, for a total of $1400. 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 inpatient hospital services you received from June 18, 2021, to June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested drug have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on March 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. 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 domiciliary visit provided on March 30, 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 physical therapy evaluation provided by a physical therapist on August 7, 2020.

You asked the Plan to pay for the physical therapy evaluation. The Plan denied your request. The Plan says there is a more appropriate code for the billed service.

The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation provided by a physical therapist on August 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 15, 2020.  You asked the Plan to pay for the subsequent hospital care. You say that this claim was taken back for no reason. You also say that you saw the enrollee on their date of death. 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 enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76377) provided on August 3, 2021.  You asked the Plan to pay for 3D rendering with interpretation and reporting of advanced imaging services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because documentation to support the medical necessity of the services at issue has not been provided.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D rendering with interpretation and reporting of advanced imaging services have not been met. Specifically, the provided medical records do not document medical necessity for the services at issue because the records do not address prior not alternative imaging. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76377) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies provided on September 23, 2020.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.  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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the single bitewing x-ray (D0270) provided on April 3, 2021.  You asked the Plan to pay for the dental service. You say that the actual work took place on the Saturday before Easter. You say that your regular dentist was not open. You say that your toothache became very painful. You say that you could not wait until Monday to seek care. You also say that this dentist could not contact your regular dentist to obtain x-rays. The Plan denied your request. The Plan says 1 set of bitewing x-rays is covered per plan year. The Plan also says that the frequency limit 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.  Though the Plan offers a dental benefit in excess of Medicare coverage and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a set of bitewing x-rays that you received on January 20, 2021. Therefore, we decided that the Plan does not have to pay for the single bitewing x-ray (D0270) provided on April 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on July 2, 2021.
You asked the Plan to pay for the services provided. You say that the services were necessary. The Plan denied
your request. The Plan says the code has processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
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 a bundled code. Payment is subsumed by the payment for the services to
which they are incident. Therefore, we decided that the Plan does not have to pay for the anesthesia services
provided on July 2, 2021.
After looking at all of the information in this case, we found that you do not owe any money for the services at
issue in this appeal. If the provider is billing you for charges beyond any applicable cost-sharing amounts,
please contact the Plan directly
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires
a trial of Orthovisc and Monovisc before it will approve Gelsyn-3.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Gelsyn-3. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The
documentation does not support that these drugs would likely be less effective and/or have adverse effects 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Gelsyn-3
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of genicular radiofrequency ablation in the setting of knee pain have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850) addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925).  You asked the Plan to pre-approve a custom molded knee for current leg prosthesis. You say that the prosthetic is not working properly, and you would like to appeal. The Plan denied your request. The Plan says the medical records submitted does not support medical necessity of the requested custom molded knee.  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 a custom molded knee for current leg prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a right above knee amputation. A custom molded knee was requested for a prosthesis. The prosthesis is new from 2/2021. The provided notes state that the enrollee has a poor fit of the socket and lack of suction, which leads to him falling. This is sufficient to support the modification to the existing prosthetic so that it fits better, however, the request for a custom orthotic rather than modifying the existing one is not supported. The LCD criteria is not met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a custom molded knee for current leg prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) addition, endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850) addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the allograft rendered on May 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 procedure code 20930 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 20930 (allograft, morselized, or placement of
osteopromotive material, for spine surgery only [list separately in addition to code for primary procedure]) has
a status indicator of B and no separate payment. Therefore, we decided that the Plan does not have to pay for
the allograft rendered on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on July 21, 2021.

You asked the Plan to pay for the dental service. You say that you called the plan prior to receiving the service to confirm that the provider was in network. You say that you were initially told by the provider office that they were out of network. You also say that an infection formed. The Plan denied your request. The Plan says 1 emergency oral evaluation is covered every 12 months. The Plan also says that the frequency limit 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral exam that you received on April 12, 2021. Therefore, we decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on July 21, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home infusion/specialty drug administration (99601) provided on
May 6, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration. You say that there were two
nursing visits this same day. The Plan denied your request. The Plan says that this is an exact duplicate claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not forwarded any evidence that this code has been paid for the
same date of service. Additionally, the record clearly indicates that the enrollee received multiple services on
the same date. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay
for the home infusion/specialty drug administration (99601) provided on May 6, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services (81401, 81403, 81404, 81405, 81406) provided on December 2, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.  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 codes 81401, 81403, 81404, 81405, and 81406, are column II codes to column I code 81439. 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 lab services (81401, 81403, 81404, 81405, 81406) provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home INR test materials you received from May 5, 2021, to June 30, 2021.
You asked the Plan to waive the coinsurance for the home INR test materials. You say that you were under the impression that you would not be charged coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment and supplies. You have been asked to pay 20% coinsurance for the home INR test materials. The home INR test materials falls within the durable medical equipment and supplies benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the coinsurance for the home INR test materials you received from May 5, 2021, to June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not
covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on March 8, 2021