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

 We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 31, 2021.  You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say that the patient was not inpatient anywhere on this date of service. The Plan denied your request. The Plan says member was inpatient under UB Claim: 210217661923). The ambulance should be billing the hospital for the ambulance run during this inpatient stay per CMS Claims processing manual, 14), 1886(d) and (g) of the Social Security Act as well as CFR 411.15(m).  The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is considered "patient transportation" and is covered as an inpatient hospital service.  We looked at the file and Medicare rules. In this case, the documentation has determined the enrollee was transported to another facility temporarily for care. This is not separately payable from the inpatient services according to Medicare rules. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the root canal obstruction (D3331), core build up (D2950), and cone beam computed tomography (CT) image capture (D0380) provided on June 26, 2021.  You asked the Plan to pay for the dental services. You say that the coverage for this procedure was verified by the provider's office. You say that you were advised you would only have to pay $600 out of pocket. You also say that you are being charged for an additional $280. The Plan denied your request. The Plan says the root canal obstruction, core build up, and cone beam CT image capture 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 root canal obstruction, core build up, and cone beam CT image capture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal obstruction (D3331), core build up (D2950), and cone beam computed tomography (CT) image capture (D0380) provided on June 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) of the brain and computed tomography angiography (CTA) of the upper and lower belly for the enrollee.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is no recommendations for these scans in the notes provided.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scans are not medically reasonable or necessary. Our physician reviewer found the workup for the enrollee to date has not included CTA of the neck as suggested - Current Procedural Terminology (CPT) 70498. There is no rationale given for the request of CTA of the abdomen and pelvis (CPT 74174). Likewise the rational for CT of the brain is not clear.  It is not certain whether there is a need for CTA of the brain as symptoms have not changed since 2019. Prior to any authorization of CT or CTA further clinical clarification is required in order to establish medical necessity.  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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the brain and computed tomography angiography (CTA) of the upper and lower belly for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray (73501) provided on September 6, 2021.  You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately 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, we have confirmed that code 73501 is a column II code to column I code 73503. 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 an x-ray (73501) provided on September 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nerve conduction studies (95913) provided on April 29, 2021.  You asked the Plan to pay for the nerve conduction studies. 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. The rules say it is expected that healthcare professionals who perform electrodiagnostic (ED) testing will be appropriately trained and/or credentialed, either by a formal residency/fellowship program, certification by a nationally recognized organization, or by an accredited post-graduate training course covering anatomy, neurophysiology and forms of electrodiagnostics (including both NCS and EMG) acceptable to this Contractor in order to provide the proper testing and assessment of the patient's condition and appropriate safety measures. In this case, the file shows that the provider did not bill as required by Medicare criteria. The provider's specialty is inconsistent with having the training required to perform electrodiagnostic testing. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies (95913) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spectacles fitting rendered on January 25, 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 the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.   The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the spectacles fitting rendered on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the phlebotomy services (99195) provided on June 1, 2021.  You asked the Plan to pay for code 99195. 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. In this case, the enrollee received services (99195) while in an outpatient hospital setting. Per Medicare payment guidelines, code 99195 has a PC/TC indicator of 5 and payment may not be made for this code when provided to patients in an outpatient hospital setting. Therefore, we decided that the Plan does not have to pay for the phlebotomy services (99195) provided on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided October 12, 2021.  You asked the Plan to pay for the diagnostic service. You say that you feel this charge should be paid as part of the Plan's preventative medicine policies. The Plan denied your request. The Plan says there is no supporting documentation for medical necessity for more frequent scan  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 the diagnostic service.  Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's last DEXA scan was 5/15/2020. There was no specific clinical rationale for obtaining a DEXA scan prior to the recommended every 24 months. There was no history of recent fracture. The review has determined that the items/services at issue in this case were 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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 20, 2021.  You asked the Plan to pay for the comprehensive oral exam. You say that you would like this exam covered instead of the previous exam. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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 Plan covers the comprehensive oral exam once per calendar year.  We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic oral exam was previously covered on July 2, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endovascular revascularization rendered on June 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 the claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 endovascular revascularization rendered on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with expandable controller and harness with electronic connection.  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 medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria are met.  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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that the enrollee has increased muscle tone or spasticity. As the enrollee does not meet criteria for the tilt and recline features, then he does not meet criteria for coverage of a group 3 power wheelchair with multiple power options (tilt and recline). Given that the wheelchair base is not medically necessary, the expandable controller with harness and electronic connection are also 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with expandable controller and harness with electronic connection.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services provided on October 18, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 injection services provided on October 18, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve massage therapy.  You asked the Plan to pre-approve massage therapy. You say that the enrollee has chronic back pain due to arthritis that is generally cyclical. You say that many patients find modalities like massage therapy quickly get flare ups back down to baseline and this decreases pain and suffering and improves function. You say as a recent custodian, your patient requires such modalities to get back to working. The Plan denied your request. The Plan says although the enrollee could benefit from the massage therapy, the requested care is excluded on her plan per Medicare Guidelines.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided December 1, 2020, to December 2, 2020.  You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that you would like the Plan to clarify your copayment. The Plan denied your request. The Plan says the copayment was applied 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 $200 copayment per day, days 1-7 of inpatient hospital care.   You have been asked to pay a $200 copayment for the inpatient hospital admission and services. The inpatient hospital admission and services falls within the Inpatient hospital 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 inpatient hospital admission and services provided December 1, 2020, to December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).  You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee needs to get to appointments. The Plan denied your request. The Plan says the benefit only allows 100 one-way trips with each one-way trip not exceeding 50 miles of driving distance.  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 routine transportation when the driving distance for a one-way trip is within 50 miles.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 84 miles away from the enrollee's residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the thorax provided on October 7, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you have never paid for these services before. The Plan denied your request. The Plan says you have been charged 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 $125 copayment for advanced imaging services provided at a free-standing radiological facility.   You have been asked to pay a $125 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the thorax provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 1, 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 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 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 imaging services provided to the enrollee on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88312, 88305) provided on September 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you currently work with a number of doctor groups who are participating providers and use your services. You also say that the patient does not go to your laboratory, so he/she is not using out-of-network benefits as his/her participating doctor sends you the specimens to process. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 laboratory services (88312, 88305) provided on September 24, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided July 27, 2021.  You asked the Plan to pay for the PET scan. You say that the PET scan was medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code.  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 code 78815 is not supported in the medical record. Specifically, R16.1 is not listed as a valid diagnosis code for this procedure. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (36556, 93350, 93312, 00567) provided June 25, 2020.  You asked the Plan to pay for the anesthesia services. You say that this service was 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 anesthesia services was not filed until November 19, 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 anesthesia services (36556, 93350, 93312, 00567) provided June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on September 15, 2021.  You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be covered. 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 $375 copayment for days 1-5 of Inpatient Hospital Care.    You have been asked to pay a $375 copayment for one day of inpatient hospital care. 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 an inpatient hospital stay provided on September 15, 2021.