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

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), ground mileage (A0425), and routine disposable supplies (A0382) provided to and from the physician office on August 20, 2021.

You asked the Plan to pay for the transportation services provided to and from the physician office. You say that the transportation services were medically necessary. The Plan denied your request. The Plan says non-emergency transportation to and from a physician office is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. 

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), ground mileage (A0425), and routine disposable supplies (A0382) provided to and from the physician office on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments applied to inpatient hospital services provided on August 27 - September 9, 2020.
You asked the Plan to waive the copayments applied to the inpatient hospital services. The Plan denied your request. The Plan says the copayments were appropriately applied to 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment per day, for days 1-5 of an inpatient hospital stay. The enrollee has been asked to pay a $275 copayment per day, for days 1-5 of the inpatient hospital stay, totaling $1,375. The inpatient hospital services fall within the inpatient hospital care 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 copayments applied to inpatient hospital services provided on August 27 - September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new
patient (99344) rendered by the OON provider on July 2, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the home visit for the evaluation and management of a new patient (99344) rendered
by the OON provider on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic agent injection of the paravertebral facet joint (64495) provided on June 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a diagnostic or therapeutic agent injection of the paravertebral facet joint. You say that the diagnosis supports medical necessity. You also say to please process this claim for payment. The Plan denied your request. The Plan says although the original claim denial was not for meeting Medicare criteria, the services are not authorized because the providers are non-network providers who do not work with the member's health plan, and the member self-directed for care. The Plan also says that the member's primary care provider did not refer for services.

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 a diagnostic or therapeutic agent injection of the paravertebral facet joint (64495) provided on June 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator.
You asked the Plan to pre-approve portable oxygen concentrator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 portable oxygen concentrator. Our reviewer says that the documentation does not support that the requested portable oxygen concentrator is medically reasonable or necessary. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD) with hypoxemia requiring supplemental oxygen. There is no documentation that portable compressed oxygen tanks cannot meet your needs for mobility. The portable tanks would last longer with a lower oxygen flow rate and/or an oxygen conserving device. Oximetry testing during activity with oxygen is needed to determine oxygen needs. Medicare does not cover a portable oxygen concentrator when the need for portable oxygen can be met with portable tanks. And a portable oxygen concentrator generally must be used with an oxygen conserving device. Therefore, you do not meet criteria for the requested device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on October 26, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.
Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on August 30,
2021, by an OON provider.

You asked the Plan to pay for the interrogation device evaluation. You say that the service was medically
necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the interrogation device evaluation provided on August 30, 2021,
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cost of parking and gas used to get to and from a medical facility.

You asked the Plan to pay for parking and gas. You say that you do not know why these services are being denied and you do not understand which items are being denied based on the information provided by the Plan. The Plan denied your request. The Plan says gas and parking pass costs for your personal vehicle are not eligible for reimbursement under your flex benefit.

The Plan offers a flex benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. This benefit includes medically necessary transportation, including taxi services, bus fare, subway fare, and transportation vans to and from Plan-approved locations. 

The Plan's rules for reimbursement of flex benefits have not been met because parking costs and gas for a personal vehicle are not listed as covered items/services under the flex benefit. Therefore, we decided that the Plan does not have to pay for the cost of parking and gas used to get to and from a medical facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an eye exam provided on March 18, 2021.
You asked the Plan to waive the deductible for the eye exam. You say that you were not aware of any deductible. The Plan denied your request. The Plan says the correct amount was applied to your deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $198 deductible which applies to certain items and services, including eye exams. The item or service you asked the Plan to waive the deductible for falls within the Vision Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $198 deductible which applies to certain items and services, including eye exams. This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on March 18, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an eye exam provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 17, 2021.
You asked the Plan to pay for the services provided. You say that the medical records support the claim. The Plan denied your request. The Plan says no separate payment is made.
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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on January 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on June 2, 2021.

You asked the Plan to pay for the ambulance treatment without transport. You say that your family member called the ambulance when you were found unresponsive. The paramedics were able to revive and stabilize you, and transport to the hospital was not necessary after treatment. You do not understand why this claim would be denied when all the services provided were necessary. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no transport is 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 June 2, 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 without transport (A0998) provided on June 2, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Repair of blepharoptosis (67904).

You asked the Plan to pre-approve Repair of blepharoptosis (67904). You say that the requested Repair of blepharoptosis (67904) is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested Repair of blepharoptosis (67904).

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 Repair of blepharoptosis (67904). Our reviewer says that the enrollee meets criteria for the requested Repair of blepharoptosis (67904). Our physician reviewer found the record indicates that the enrollee has loss of vision due to droopy eyelids and has bilateral dermatochalasis with a recorded MRD1 of 1 mm. The elements of the coverage criteria are satisfied. The requested service is 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 Repair of blepharoptosis (67904) have been met. Therefore, we decided that the Plan has to pre-approve Repair of blepharoptosis (67904).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteotomy of spine services coded 22224 and the anterior instrumentation services coded 22845 provided on August 9, 2021.

You asked the Plan to pay for the osteotomy of spine services and the anterior instrumentation services. 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 supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 22224 and 22845 are not supported in the medical record. Specifically, code 22224 was billed with AS modifier (assistant surgeon). An osteotomy of spine, including discectomy, by an anterior approach, for a single lumbar vertebral segment is not eligible for assistant surgeon reimbursement. Code 22845 was also billed with and without AS modifier (assistant surgeon).

The operative report did not include documentation of anterior instrumentation; for 2 to 3 vertebral segments (listed separately in addition to code for primary procedure); therefore, code 22845 with the assistant surgeon modifier cannot be verified. While procedure code 22845, an anterior instrumentation for 2 to 3 vertebral segments (listed separately in addition to code for primary procedure) is documented in the operative note submitted for review; however, this procedure is considered inclusive to CPT code 22853 x2, an insertion of a interbody biomechanical device(s) (synthetic cage, mesh) with integral anterior instrumentation for device anchoring (screws, flanges) when performed, to intervertebral disc space in conjunction with interbody arthrodesis, for each interspace (listed separately in addition to code for primary procedure); therefore, code 22845 cannot be verified.

Based on this information, we decided that Medicare rules for coverage of the osteotomy of spine services and the anterior instrumentation services have not been met. Therefore, we decided that the Plan does not have to pay for the osteotomy of spine services coded 22224 and the anterior instrumentation services coded 22845 provided on August 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 20, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you went in for a spider bite and
they did nothing to treat it which resulted in you having to return with chest pains. 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 $75
copayment for emergency care.
You have been asked to pay a $75 copayment for emergency care. Emergency care 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 emergency care provided on July
20, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services of a surgical assistant at an endovascular repair of
infrarenal aorta and/or iliac arteries (34705) and a percutaneous access and closure of femoral artery (34713)
provided on August 16, 2021.

You asked the Plan to pay for surgical assistant services at an endovascular repair of infrarenal aorta and/or
iliac arteries and a percutaneous access and closure of femoral artery. You say that the services at issue were a
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not
been met because the provider of the services at issue is not eligible for enrollment in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has denied this service stating that the provider is
ineligible for payment. The record clearly indicates that this provider is a CNS. A CNS is eligible for payment
according to the Medicare rules. The Plan has not forwarded any evidence to show why these services would
not be payable. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay
for the services of a surgical assistant at an endovascular repair of infrarenal aorta and/or iliac arteries (34705)
and a percutaneous access and closure of femoral artery (34713) provided on August 16, 2021.

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.