Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the selective catheter placement provided on January 15, 2021.
You asked the Plan to pay for the selective catheter placement. You say that the attached records support CPT 36223 and payment should be processed. The Plan denied your request. The Plan says the records do not support the service 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 36223 is selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed.
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 selective catheter placement. Our reviewer says that this does not meet criteria for billing or reimbursement consideration. Our reviewer found that the medical records submitted do not include sufficient documentation to validate that procedure 36223 50 59 was performed as a distinct separate service from 37215. Our reviewer says that the services were performed by the same provider during the same session on January 15, 2021, therefore, this service is inclusive to 37215 and separate reimbursement is not allowed. 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 selective catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement provided on January 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you rely on this transportation to attend 
appointments for treatment. The Plan denied your request. The Plan says the requested service is covered under 
the plan, but the requested amount exceeds the limit listed by the plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  

We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on
February 10, 2021.

You asked the Plan to waive the copayment for a medical eye exam. You say that you disagree with the
charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 physician services for the diagnosis and treatment of diseases and injuries of the eye,
including treatment for age-related macular degeneration for vision care.

You have been asked to pay a $10 copayment for a medical eye exam. The records show that you had a
cataract check in both eyes and were diagnosed with presbyopia. The EOC confirms that $10 is the required
copayment for this service. A medical eye exam falls within the vision 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 a medical eye exam (92014) provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the fully reclining wheelchair (E1050) and sales tax (S9999) provided on April 12, 2021.
You asked the Plan to pay for the fully reclining wheelchair and sales tax. You say that you would like reconsideration because the Plan paid for the gel pad but not the wheelchair. The Plan denied your request. The Plan says Medicare and the plan will only cover the rental of fully reclining wheelchairs from approved suppliers and will not cover the cost of purchasing one. must follow Medicare rules. Medicare rules say that for capped rental items, contractors pay the fee schedule amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a purchase option. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the fully reclining wheelchair and sales tax have not been met. Specifically, the record indicates that you purchased the reclining wheelchair. This equipment is a capped rental item and Medicare does not cover payment for this equipment when purchased. Additionally, Medicare does not pay for sales tax. Therefore, we decided that the Plan does not have to pay for the fully reclining wheelchair (E1050) and sales tax (S9999) provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), comprehensive oral evaluation (D0150), panoramic x-ray (D0330), two surgical removals of an erupted tooth (D7211 x2), and deep sedation/general anesthesia (D9220 and D9223) provided from January 22, 2020, to March 15, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation, comprehensive oral evaluation, panoramic x-ray, surgical removals of an erupted tooth, and deep sedation/general anesthesia. You say that the treating provider does not participate in Medicare and refused to submit the claims to your insurance. You also
say that you believe you should be reimbursed $540.00 because part of these procedures are covered by the Plan. The Plan denied your request. The Plan says the claim for the cone beam CT capture and interpretation (D0364) was submitted on May 4, 2021, which is past the 12-month timeframe for this service provided on January 22, 2020. The Plan also says that these services were rendered by a Medicare opt out provider, and you will not be reimbursed for these services.
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. 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. The record shows that a claim for the cone beam CT capture and interpretation was not filed until May 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), comprehensive oral evaluation (D0150), panoramic x-ray (D0330), two surgical removals of an erupted tooth (D7211 x2), and deep sedation/general anesthesia (D9220 and D9223) provided from January 22, 2020, to March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) extended monitoring (95813) and short-latency somatosensory evoked potential study (95927) provided on February 19, 2021.

You asked the Plan to pay for the EEG extended monitoring and short-latency somatosensory evoked potential study. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claims have denied correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service code. 

We looked at the file and Medicare rules. Based on this information we determined that Medicare criteria for coverage have not been met. Specifically, this claim was not billed with the appropriate place of service code. The place of service code should reflect the facility this provider was serving. Additionally, payment for the technical component of the billed services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the EEG extended monitoring and short-latency somatosensory evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) extended monitoring (95813) and short-latency somatosensory evoked potential study (95927) provided on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
May 13, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the administration of the PNEUMOVAX-23 vaccine.
You asked the Plan to pre-approve the PNEUMOVAX-23 vaccine. You say that this vaccine is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says only one dose is given at age 65 years or older.
The Plan must follow Medicare rules. Medicare rules say that an initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccination under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered. We looked at the file and Medicare rules. Specifically, the enrollee received an initial vaccine on August 30, 2021 and 1 year has not passed since this occurred. Based on this information, we decided that Medicare rules for coverage of the PNEUMOVAX-23 vaccine have not been met. Therefore, we decided that the Plan does not have to pre-approve the administration of the PNEUMOVAX-23 vaccine.
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 the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercise to develop strength, endurance, range of motion and flexibility, each 15 minutes) (CPT code 97110), application of mechanical traction to 1 or more areas (CPT code 97012), chiropractic manipulative treatment to 1 or more regions other than spine (CPT code 98943), application of electrical stimulation to 1 or more areas, unattended by physical therapist (CPT code 97014) and therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110) provided to the enrollee from October 20, 2020, through November 30, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered under the enrollee's contact under any normal circumstances. The Plan states they have limited chiropractic benefits and these services are excluded.
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. These services are excluded from Medicare coverage when performed by a Doctor of Chiropractic. Therefore, we decided that the Plan does not have to pay for CPT code 97110, CPT code 97012, CPT code 98943, CPT code 97014 and CPT code 97110, provided to the enrollee from October 20, 2020, through November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for custom ear molds for hearing aids (V5267), provided on June 14, 2018.

You asked the Plan to pay for custom ear molds for hearing aids. You say that the item should be covered. The Plan denied your request. The Plan says you do not have out-of-network hearing benefits.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when hearing services are received from a network hearing or hearing aid provider, they will be covered as indicated in the Evidence of Coverage. 

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of custom ear molds for hearing aids have not been met. Specifically, you received this service from an out-of-network provider. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for custom ear molds for hearing aids (V5267), provided on June 14, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV) described by
code K0808.
You asked the Plan to pre-approve 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. Medicare rules say that a Group 2 POV is denied as not reasonable and
necessary.
We looked at the file and Medicare rules. The item at issue is a Group 2 POV described by code K0808. This
item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to
pre-approve a Group 2 power operated vehicle (POV) described by code K0808.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for wound care.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested services are available in-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for wound care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (up to 
2 hours) (CPT code 99601) provided to the enrollee from March 25, 2021, through April 8, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed by the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.

Per the 2021 National Physician Fee Schedule Relative Value File for January and April Release, CPT code 
99601 is assigned a status code I = Not valid for Medicare purposes. As the claim was billed with a CPT code 
which is invalid for usage with Medicare; we find that Medicare rule for payment of this claim has not been 
met. Therefore, we decided that the Plan does not have to pay for home infusion/specialty drug administration, 
per visit (up to 2 hours) (CPT code 99601) provided to the enrollee from March 25, 2021, through April 8, 
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the chemotherapy treatment including the
drug Rituxan you received at an outpatient hospital facility on June 3, 2021.

You asked the Plan to waive the cost sharing for the chemotherapy treatment and Rituxan. You say that no one
ever told you there would be a cost associated with this. You stated that if you had known the cost, you would
not have had it done. 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 have a $750
deductible that must be met before the Plan will start paying for your care.

After the deductible is met, you must pay a $125 copayment for services at an outpatient hospital facility and
20% coinsurance for Medicare Part B drugs.

You had not yet met your $750 deductible prior to these services, which is why you were charged this amount.
After the deductible was satisfied, you have been charged a $125 copayment for the chemotherapy treatment
and 20% coinsurance for the Rituxan. 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 cost sharing for the chemotherapy
treatment including the drug Rituxan you received at an outpatient hospital facility on June 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient provided on December 17, 2020.

You asked the Plan to pay for the outpatient visit. You say that the services that were rendered to the enrollee were medically necessary. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on December 14, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient provided on December 17, 2020.