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

We decided that the Plan does not have to pre-approve cooled 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 there was only one month of relief documented.

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 cooled radiofrequency ablation is not covered by Medicare. Additionally, the prior radiofrequency ablation session only provided a month of pain relief. There needs to be a minimum of six months. For these reasons, the request is deemed not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel (R0070) provided on July 7, 2021.

You asked the Plan to pay for code R0070. 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 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, the CPT Code Manual definition of code R0070 is Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. 

We find that CPT code R0070 is not supported in the medical record. The provider reported transportation of portable radiology equipment but did not report setup codes, which does not follow industry standard coding rules. Transportation services are not reimbursable without the reporting of setup services. Diagnostic x-ray setup and transportation services were not performed by the portable x-ray provider. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel (R0070) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the postoperative follow-up visit (99024) provided on June 10, 2021.

You asked the Plan to pay for code 99024. 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Code 99024 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the postoperative follow-up visit (99024) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (00142 and 99100) provided on February 15, 2021.

You asked the Plan to pay for codes 00142 and 99100. 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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, there were no medical records provided to verify the units billed for code 00142. The anesthesia records submitted do not indicate the anesthesia end time, therefore, the number of units cannot be verified. 

The rules also say that providers must report services correctly. Code 99100 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00142 and 99100) provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 6, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that this was your annual cleaning that you get every 6 months. The Plan denied your request. The Plan says a comprehensive oral exam is only covered once every 36 months.

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, you also have a maximum benefit of one comprehensive oral evaluation every 36 months. The Plan paid for the comprehensive oral evaluation provided on October 7, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 26, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that you cannot afford this bill. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $110 copayment for each covered emergency room visit. 

You have been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 the emergency room visit provided on June 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that the enrollee reports back pain and stiffness. The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are not covered by Medicare.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of documentation about the duration and degree of pain relief from the first set of diagnostic medial branch blocks. Because of this lack of documentation, the request is not considered medically reasonable or 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lenses provided on August 17, 2021.

You asked the Plan to pay for the polycarbonate lenses. You say that this is the first time you used benefits and the claim should be reprocessed to pay. The Plan denied your request. The Plan says the benefit for polycarbonate lenses is exhausted because the Plan covered progressive lenses.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover polycarbonate lenses as an upgrade option. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate lenses have not been met. Specifically, polycarbonate lenses are not a covered upgrade option. Therefore, we decided that the Plan does not have to pay for the polycarbonate lenses provided on August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99222) provided on February 27, 2021.  You asked the Plan to pay for the initial hospital care (99222). 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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no medical records provided to verify if the services were billed appropriately per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided on February 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 laboratory services provided on March 15, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (procedure code 73564) provided to the enrollee on June 3, 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 this was billed without the required anatomical modifier.

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 73564 is "Radiologic examination, knee; complete, 4 or more views." 

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 the documentation does include a radiology report as well as billing documentation to confirm accuracy. CPT 73564 would require an anatomical modifier. When performing a procedure which has bilateral components, a modifier would be appended to identify where the procedure was performed.

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 radiology services (procedure code 73564) provided to the enrollee on June 3, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve additional doses of Keytruda.  

You asked the Plan to pre-approve Keytruda. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says that the criteria for coverage 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 medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee has been diagnosed with non-small cell lung cancer. They have been stable on Keytruda. In this case, the requested drug is FDA-approved for the enrollee's condition. Specifically, the enrollee has had stable imaging and the bronchoscopy confirming lung cancer is not necessarily indicative of progression.  

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 been met. Therefore, we decided that the Plan has to pre-approve additional doses of Keytruda.   

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for proton beam therapy services provided January 26, 2021 to February 17, 2021.

You asked the Plan to pay for proton beam therapy. You say that proton beam therapy is the best option based on the enrollee's condition and must be considered as medically necessary. The Plan denied your request. The Plan says proton beam radiation therapy is not the standard of care for prostate cancer and proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial.

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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The Medicare criteria has not been 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pay for proton beam therapy services provided January 26, 2021 to February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 21, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network providers are not covered.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on June 21, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on June 27, 2021.  

You asked the Plan to pay for code 70450. 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 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 70450 is a column II code to column I code 70496. 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 computed tomography (CT) scan (70450) provided on June 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 28, 2020.

You asked the Plan to waive the copayment for the laboratory work. You say that you disagree with the copayment you are being asked to pay. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $5 copayment per day for Medicare-covered laboratory services.

This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple labs are performed. 

You have been asked to pay a $5 copayment for the laboratory work. The laboratory work 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 the laboratory work provided on September 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) provided April 17, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you don't feel you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for these services. 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 ambulance services (A0427) provided April 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure codes 95885, 95907, 95927, 95937, 95955) provided to the enrollee on July 20, 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 records do not support the services 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, the CPT Code Manual definition of the denied codes is:  

CPT 95885:  Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)   
CPT 95907:  Nerve conduction studies; 1-2 studies  
CPT 95927:  Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head  
CPT 95937:  Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method  
CPT 95955:  Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)  

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 for CPT 95907, the procedure report does not include documentation of nerve conduction studies, which measures amplitude and latency/velocity. The report describes pedicle screw stimulation. This is an incorrect procedure code to report for this service. For CPT 95885, per the code description, this procedure is done with nerve conduction studies. The technical report does not include documentation of nerve conduction studies, and therefore this procedure would not be covered. In terms of CPT 95927 and CPT 95937, these procedures are not found in the procedure report. In terms of CPT 95955, the procedure report describes real time monitoring. This is the incorrect code to use for this service. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report. Any additional testing would be inclusive to the correct code reported for intraoperative monitoring.  

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 surgical services (procedure codes 95885, 95907, 95927, 95937, 95955) provided to the enrollee on July 20, 2021.