Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure provided to the enrollee.  

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy.  

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 75635) provided to the enrollee on July 29, 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 an appropriate first-listed diagnosis code was not billed for this service.  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 75635 is "Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including non-contrast images, if performed, and image postprocessing."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found per the ICD-10 guidelines "code first atherosclerosis of arteries of the extremities (I70.2; I70.3; i70.4; I70.5; I70.6; I70.7)." Diagnosis codes should always be reported to the highest specificity, in this case there is another code that should be coded first.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 75635) provided to the enrollee on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a laboratory test provided on September 23, 2021.  You asked the Plan to waive the copayment for the laboratory test. You say that there should be no charges as you never had these services and didn't go in to see anyone. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 Outpatient diagnostic tests and therapeutic services and supplies.      You have been asked to pay a $10 copayment for a laboratory test. The Plan sent us medical records confirming that there were services provided on September 23, 2021.  Laboratory tests fall 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 a laboratory test provided on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the puncture drainage of a lesion (10160) provided on May 13, 2021.

You asked the Plan to pay for the puncture drainage of a lesion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is included in the global surgery period of another procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 10160-78 is not supported in the record. Specifically, the documentation submitted does not support the billing of modifier 78. The records do not indicate that this service involved a return trip to the operating room. Based on this information, we decided that Medicare rules for coverage of the puncture drainage of a lesion have not been met. Therefore, we decided that the Plan does not have to pay for the puncture drainage of a lesion (10160) provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor.

You asked the Plan to pre-approve a Dexcom continuous glucose monitor. You say that this should be covered. The Plan denied your request. The Plan says the requirements for coverage 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 indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation service provided on May 20, 2021.

You asked the Plan to pay for the transportation service. The Plan denied your request. The Plan says the
routine transportation was not obtained in accordance with the Plan rules and no reimbursement can be issued.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the transportation service have not been met. This provider is not part of the Medicare program and
is not payable. Therefore, we decided that the Plan does not have to pay for the transportation service provided
on May 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on October 6, 2021.

You asked the Plan to pay for the hot or cold packs therapy. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this service is included in another service provided at the same time and this code is not allowed to be billed separately.

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 97010 is hot or cold packs therapy. 

We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that payment for CPT code 97010 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) provided on October 4, 2021.

You asked the Plan to pay for the dental service. You say that this service has been reimbursed in the past. You say that you do not understand why it was denied this time. The Plan denied your request. The Plan says there is a $750 allowance for dental services every year. The Plan also says that the allowance 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 cleanings are listed as covered, the annual allowance has been exceeded.

Additionally, the Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) provided on October 4, 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 19, 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 an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 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 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided on October 26, 2021.

You asked the Plan to pay for the prefabricated post and core. You say that it is not acceptable that the policy covers the crown but not the posts. You also say that the crown and post and core need each other, are necessary, and a combined procedure. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that post and core is always billed separately from a crown and is not a covered service on any Medicare dental 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 the prefabricated post and core in addition to crown (D2954) provided on October 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that the requested Aduhelm is medically necessary. The Plan denied your request. The Plan says the requested Aduhelm is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Aduhelm. Our reviewer says that the requested Aduhelm is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of unspecified Alzheimer's disease. The record provided does not include the results of neurocognitive testing or Magnetic resonance imaging (MRI) demonstrating amyloid plaques consistent with the required diagnosis for 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 drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950), and porcelain crown (D2740) provided on July 22, 2022.

You asked the Plan to pay for the dental services. You say that the provider office confirmed with your insurance that the crown would be covered. You also say that now your insurance is saying that it is not covered. The Plan denied your request. The Plan says core build up and porcelain crown are not listed as covered services.

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 core build up and porcelain crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), and porcelain crown (D2740) provided on July 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) provided on August 17, 2021.   You asked the Plan to waive the coinsurance for the onabotulinumtoxina injection. You say that the services should be covered as you received a letter stating they would be covered under your Part D Plan. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  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 Medicare Part B prescription drugs.    You have been asked to pay a 20% coinsurance for the onabotulinumtoxina injection (allowed is $1,215.20 x 20% = $243.04). This injection was provided in an outpatient setting, which is why it was billed under Part B.  Onabotulinumtoxina injections fall within the Medicare Part B prescription drugs 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 an onabotulinumtoxina injection (J0585) provided on August 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 4, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 911 because the enrollee fell and could not get up. You also say that the enrollee did not have the need to go to a hospital and therefore did not use the ambulance. The Plan denied your request. The Plan says the enrollee's plan covers ambulance transportation only when they are actually transported by ambulance. The Plan also says that since the enrollee was not transported by this ambulance, the service is not covered by the Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on August 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) and manual therapy techniques (97140) provided on July 14, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the therapeutic exercises and manual therapy techniques. You say that there are no in-network providers in the area, and you believe this claim should be reprocessed for medical necessity. The Plan denied your request. The Plan says both the referring and attending providers are non-participating with the Plan. The Plan also says that prior authorization was not obtained by the provider or facility.

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. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) and manual therapy techniques (97140) provided on July 14, 2021 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 problem focused limited oral evaluation (D0140) provided on September 29, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you cannot pay this which is why you have insurance to help you. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 the problem focused limited oral evaluation (D0140) provided on September 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 25, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance transport was not medically necessary, and the enrollee should be responsible for the entire bill. The Plan denied your request. The Plan says the claim processed correctly 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $290 copayment for Non-Emergency Ground Ambulance services. The total amount allowed was $280.38 which is less than the copayment amount of $290. 

The enrollee has been asked to pay a $280.38 copayment for ambulance services. The ambulance services falls within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care office visit (99213) provided on May 6, 2021, July 8, 2021, and August 19, 2021.  You asked the Plan to waive the copayment for the primary care office visit. You say that the services should be covered as they would cause a financial hardship The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $15 copayment for Physician/Practitioner services, including doctor's office visits.     You have been asked to pay a $45 copayment for three primary care office visits ($15 x 3 = $45). 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 primary care office visit (99213) provided on May 6, 2021, July 8, 2021, and August 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no treatment (A0998) provided on May 10, 2021.  You asked the Plan to pay for the ambulance service. You say that the enrollee decided to wait and see if their condition improved. The Plan denied your request. The Plan says there was not transport provided on the date of service in this case. The Plan also says that since there was no transport provided, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on May 10, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no treatment (A0998) provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 4, 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 provided on June 4, 2021.