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

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
April 8, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were seen in the ER, and you
were advised that you were going to be admitted for further testing. There we no beds available, so you were
transferred to a different hospital and admitted. You stated that this copayment should be waived because you
were admitted to the other hospital. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that you were not admitted to the second hospital as an inpatient, rather,
you were kept in observation.
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 $120
copayment for emergency room services.
You have been asked to pay a $120 copayment for the ER visit. The medical records show that you were kept
in observation in the second hospital. Observation is an outpatient status, and it is not considered an inpatient
admission. 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 the emergency room (ER) visit you had on
April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you had a PPO plan last year and didn't know you needed a referral. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 July 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory services provided on June 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit and lab tests. You say that these services are not listed as requiring authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit and laboratory services provided on June 3, 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 additional supplies (procedure 99072) provided to the enrollee on May 10, 2021.
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says this code has a status indicator of "B."
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 not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately and is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies (procedure 99072) provided to the enrollee on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on May 17, 2021.
You asked the Plan to pay for the ConfirmMDx testing. 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 must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare only covers ConfirmMDx for males who have undergone a previous cancer-negative prostate biopsy. The file shows that this was the enrollee's first biopsy. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on May 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 23, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first for review.
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 physician services provided to the enrollee on July 23, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 20, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found that the enrollee was then a 91-year-old female with dementia. She was transported by ambulance from the hospital inpatient stay to skilled nursing facility. The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable and necessary 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular study coded 93976 provided on June 29, 2021.
You asked the Plan to pay for the vascular study. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93976
for the vascular study is a column II code to column I code 76856. 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 vascular study coded 93976 provided on
June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for X-rays provided on June 22, 2021.
You asked the Plan to waive the copayment for X-rays. You say that you did not request X-rays and just wanted your toenails clipped. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $35 copayment for X-rays. You have been asked to pay a $35 copayment for X-rays. X-rays 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 X-rays provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine dental services rendered on December 12, 2019,
to October 30, 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 are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the routine dental services
rendered on December 12, 2019, to October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Lite test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there are no indications that the enrollee cannot use the plan-preferred brands.
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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no reason given why the requested brand must be used rather than the other brands. It is unusual to be using this brand at this point. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Lite test strips
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that this device is safe and effective.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided November 1, 2019.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency room services was not filed until July 8, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontic exam.
You asked the Plan to pre-approve a periodontic exam. 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.
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 pre-approve a periodontic exam
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received on April 1, 2021 and May 6, 2021.
You asked the Plan to pay for the dental services. You say that you were not told by the provider's office that this provider was an opt out 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 on April 1, 2021 and May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 8, 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 G0483 is not supported.
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 G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records support the testing of only 15 drug classes. 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 drug testing rendered on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services monthly coded 90960 provided on March 31, 2021.
You asked the Plan to pay for the end-stage renal disease (ESRD) related services monthly. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 90960 is end-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month.
We find that CPT code 90960 is not supported in the medical record. Specifically, the documentation shows that this is a duplicate to a previously processed and paid claim. This means that this claim is not separately payable. Based on this information, we decided that Medicare rules for coverage of the end-stage renal disease (ESRD) related services monthly have not been met. Therefore, we decided that the Plan does not have to pay for the end-stage renal disease (ESRD) related services monthly coded 90960 provided on March 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) sessions (97110).
You asked the Plan to pre-approve physical therapy. You say that the enrollee's functional status is declining rapidly, and they will benefit from physical therapy intervention rather than lumbar surgery. The Plan denied your request. The Plan says the enrollee has had 19 physical therapy visits approved since June 2021. The enrollee has exhibited a significant improvement in function with therapy but has reached a plateau in improvement. The enrollee has been provided a structured home exercise program, and there is no reason provided as to why this cannot be continued going forward.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function due to low back pain. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) sessions (97110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic osteopathic manipulation therapy (98943).
You asked the Plan to pre-approve chiropractic therapy. You say that the incorrect diagnosis was put on file. The denial indicated that the Plan does not cover chiropractic manipulation services but that is incorrect as you have had this service done in the past. The Plan denied your request. The Plan says the records do not support that this is reasonable and necessary.
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. 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 chiropractic therapy Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found in this case the record indicates that the enrollee was receiving physical therapy after being found down and having decreased strength and functional ability. The provided records do not document subluxation as demonstrated by either physical examination or X-ray. The elements of the coverage criteria are not satisfied, and 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 chiropractic therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic osteopathic manipulation therapy (98943).