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

 We decided that the Plan does not have to pay for chiropractic services (S9090) provided June 1, 2021.  You asked the Plan to pay for the chiropractic services. You say that the chiropractic services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.  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 chiropractic services (S9090) provided June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair and attachments.  You asked the Plan to pre-approve a power wheelchair and attachments. You say that this is medically necessary. The Plan denied your request. The Plan says that documents indicate you are able to self-propel or have a caregiver who is available and able to provide assistance with a wheelchair.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.     The file shows that your condition can be improved by a walker, cane, or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital observation services rendered from June 29, 2021 to July 3, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that a hospital may record for each period of observation services the beginning and ending times during the hospital outpatient encounter and add the length of time for the periods of observation services together to reach the total number of units reported on the claim for the hourly observation services HCPCS code G0378 (Hospital observation service, per hour).  We looked at the file and Medicare rules. The file shows that procedure code G0378 was not billed correctly, as it was reported on two claim lines. 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 hospital observation services rendered from June 29, 2021 to July 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body (43247), and esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire (43248) provided on February 13, 2021.  

You asked the Plan to pay for the outpatient services. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  

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 esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body (43247), and esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire (43248) provided on February 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on January 21, 2021, to January 28, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that you think the Plan should pay for this. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $35 copayment for outpatient rehabilitation services. 

You have been asked to pay a $35 copayment for each physical therapy. The total amount you are being asked to pay is $140 ($35 x 4 sessions = $140). 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 provided by a participating provider on January 21, 2021, to January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 2, 2021.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill 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, we have confirmed that code 70544 is a column II code to column I code 70551. 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 imaging services provided to the enrollee on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a stair glide purchased July 22, 2021.  

You asked the Plan to pay for a stair glide. You say that the stair lifts were needed as the enrollee had no ability to exit the house and could not navigate the 2 flights of stairs without the lift. The Plan denied your request. The Plan says this item is not a covered benefit.  

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide purchased July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for gallbladder removal surgery performed on August 6, 2021.  You asked the Plan to waive the coinsurance for the gallbladder surgery. You say that the doctor made an error during the procedure that caused further health issues, and you feel that you should not be responsible for the copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 20% coinsurance for surgery in an outpatient hospital.   You have been asked to pay $145.90, which is 20% of the allowed amount for the gallbladder surgery ($729.48 allowed amount x 20% coinsurance = $145.90).  The gallbladder surgery falls within the Outpatient Surgery and Other Medical 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 coinsurance for gallbladder removal surgery performed on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for sedation services (99153) provided on July 28, 2021.  You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee schedule for Technical Component (TC) services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings.  We looked at the file and Medicare rules. The records show that the service at issue was provided in an inpatient setting, but it is a technical-component only code and is not separately payable. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection rendered on August 26, 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 62323 is not separately payable.  

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.    

The provider submitted a claim for procedure codes 62323 (interlaminar injection) and 64624 (destruction by neurolytic agent). Code 62323 is a column II code with a modifier indicator of 1 when billed with column I code 64624. Code 62323 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the injection rendered on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be safely met at a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The patient was admitted for craniotomy for resection of metastatic mass (lung primary). The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (82306) provided on March 29, 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 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (82306) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a cone beam computed tomography (CT) image capture (D0380) and endodontic therapy (D3330) provided on October 12, 2021.  

You asked the Plan to pay for a limited oral evaluation, a cone beam CT image capture and endodontic therapy. You say that this claim was for a root canal done on a tooth with a major fracture that impacted the pulp cavity. You also say, according to your Plan's manual, the Plan pays 25% of out-of-network root canals. The Plan denied your request. The Plan says the services requested are not listed as covered benefits with your Plan.  

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 a limited oral evaluation (D0140), a cone beam computed tomography (CT) image capture (D0380) and endodontic therapy (D3330) provided on October 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on October 4, 2021.  

You asked the Plan to waive the copayment for an EKG. You say that the EKG should be included in your annual checkup and prior to this date of service you never paid for it. The Plan denied your request. The Plan says the EKG was billed as a diagnostic test and the proper copayment was applied.  

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 Medicare-covered outpatient diagnostic procedures or tests.     

You have been asked to pay a $10 copayment for an EKG. An EKG falls within the Outpatient diagnostic tests and therapeutic services 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 copayment for an electrocardiogram (EKG) provided on October 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolotherapy and transcutaneous electrical nerve stimulation (TENS) therapy rendered on March 1, 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 TENS therapy for chronic low back pain (CLBP) is covered when the beneficiary is enrolled in an approved clinical study meeting specific requirements. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  We looked at the file and Medicare rules. The file shows that the TENS therapy was not provided for CLBP with an approved clinical study. The prolotherapy is an acupuncture service and is not covered. Therefore, we decided that the Plan does not have to pay for the prolotherapy and transcutaneous electrical nerve stimulation (TENS) therapy rendered on March 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial observation care (99220) provided on August 26, 2021.  You asked the Plan to pay for the initial observation care. The Plan denied your request. The Plan says the enrollee was actively enrolled in Hospice from July 19, 2021, to October 28, 2021. The Plan also says that this date of service falls within the confirmed Hospice enrollment period and the claim should be submitted to the appropriate payer.  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 initial observation care (99220) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance and copayment for medication and specialist services provided on July 21, 2021.  You asked the Plan to waive the coinsurance and copayment for the medication and the specialist services. You say that you were never informed of an additional copayment for knee medication, and you have only paid a single copayment in the prior years. The Plan denied your request. The Plan says the proper coinsurance and copayment was applied.   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 20% coinsurance for all drugs covered under Medicare Part B and a $25 copayment for Physician specialist services. The total amount allowed for the medication was $1,038.18 with a coinsurance of $207.64 ($1,038.18 total amount x 20% coinsurance). With the specialist services being charged a $25 copayment. The total cost share for the date of service was $232.64 ($207.64 coinsurance + $25 copayment).  You have been asked to pay a 20% coinsurance for medication and a $25 copayment for specialist services. The medication falls within Medicare Part B prescription drugs benefit category. The specialist services falls within the Physician/Practitioner services, including doctor's office visits 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 and copayment for medication and specialist services provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the FoundationOne CGx testing.  You asked the Plan to pay for the FoundationOne CGx testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this testing is unlikely to impact therapeutic decision making in the clinical management of the patient.  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 pay for the FoundationOne CGx testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found review of NCCN guidelines sarcoma show that there are no actionable mutations.  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 FoundationOne CGx testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CGx testing.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81539) provided July 30, 2021.  You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says this test is not covered.  The Plan must follow Medicare rules. Medicare rules say that the 4Kscore test algorithm will be denied as not medically reasonable and necessary as the available published clinical evidence does not support improved health outcomes in the Medicare patient population.  We looked at the file and Medicare rules. This test is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81539) provided July 30, 2021.