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

 We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.  You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says it is not considered the standard of care.  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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. He has tried physical therapy and a home exercise program. His magnetic resonance imaging shows L4-L5 Modic Type II changes. The request is to perform radiofrequency ablation of the basivertebral nerves. This is considered an experimental/investigational procedure. Therefore, it 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a percutaneous transluminal mechanical thrombectomy (99285, 80048, 76937, 36905, Q9967, J3490, J3010, J2997, J2250, J1644, C1894, C1769, C1725) rendered on August 13, 2021.  You asked the Plan to waive the copayment for a percutaneous transluminal mechanical thrombectomy. You say that it is not your fault the dialysis people injured your vein and you do not feel you should be held responsible for this payment. The Plan denied your request. The Plan says you were 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 $150 copayment for each outpatient surgery and/or services at an ambulatory surgical center.   You have been asked to pay a $150 copayment for a percutaneous transluminal mechanical thrombectomy. A percutaneous transluminal mechanical thrombectomy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 percutaneous transluminal mechanical thrombectomy (99285, 80048, 76937, 36905, Q9967, J3490, J3010, J2997, J2250, J1644, C1894, C1769, C1725) rendered on August 13, 2021.   Your complaint about the dialysis facility potentially hurting your vein is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Azathioprine 50mg tablet.  You asked the Plan to pre-approve Azathioprine Tablet. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.  The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Azathioprine 50mg tablet.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for observation care discharge day management (CPT code 99217) provided on July 26, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 99224 and 99217. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for observation care discharge day management (CPT code 99217) provided on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from February 18, 2021, through February 24, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly 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 $375 copayment per day, for days 1 to 5 for inpatient hospital care. The enrollee's inpatient cost share will begin on day one each time the enrollee is admitted or transferred to a specific facility type.  The enrollee has been asked to pay $1,875 ($375 copayment x 5 days) for the inpatient hospital care provided. 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 copayment for the inpatient hospital care provided from February 18, 2021, through February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an annual wellness visit provided on September 14, 2021.  You asked the Plan to pay for an annual wellness visit. You say that you were not aware your January visit had been considered your annual wellness exam. The Plan denied your request. The Plan says a second annual wellness exam cannot be paid.  The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (80053, 85025, 82306) provided on July 28, 2021.  You asked the Plan to pay for laboratory services. You say that these services are covered by Medicare. The Plan denied your request. The Plan says these services are not supported in the records.  The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician.   We looked at the file and Medicare rules. The submitted records did not include a physician order for the testing at issue. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (80053, 85025, 82306) provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an electrocardiogram (93042) provided on June 13, 2021.  You asked the Plan to pay for an electrocardiogram. You say that this is supported in the records. 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 93042 is a column II code to column I code 12002. 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 electrocardiogram (93042) provided on June 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the backup manual wheelchair repairs  You asked the Plan to pre-approve the backup manual wheelchair repairs. You say that you need this item. The Plan denied your request. The Plan says backup manual wheelchair repairs are not medically necessary because the documentation received indicates you have a primary power wheelchair that meets your mobility needs.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have. The requested item serves the same purpose as an item you currently have. Therefore, we decided that the Plan does not have to pre-approve the backup manual wheelchair repairs
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 30, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76700 (abdominal ultrasound) and 93976 (vascular study). Code 76700 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76700 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that the drug is medically necessary. The Plan denied your request. The Plan says Eliquis is a self-administered drug.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (83789, 80307, G0480) provided on June 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that most in-network providers cannot perform such complex detailed drug testing services. You also say the referring physician is a contracted provider and has received reimbursement for his/her services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. 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 drug testing (83789, 80307, G0480) provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), determination of refractive state (92015), and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) provided June 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the ophthalmic diagnostic imaging, eye refraction and medical eye exam. You say that you felt the vision services were an emergency and would like them covered. The Plan denied your request. The Plan says these services are not covered because they were provided OON.  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 covers these services when they are provided by a network provider.  We looked at the file and the Plan's rules. The Plan has network providers available who could provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for these services. Based on this information, we decided that the Plan's rules for coverage of the ophthalmic diagnostic imaging, eye refraction and medical eye exam have not been met. Therefore, we decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), determination of refractive state (92015), and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) provided June 15, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on June 2, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 22852 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 22852 is removal of posterior segmental instrumentation.  We find that CPT code 22852 is not supported in the medical record. Specifically, there is no documentation of removal of posterior segmental instrumentation. 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 surgical services rendered on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 4, 2021.  You asked the Plan to pay for periodontal maintenance. You say that your provider only submitted the claim to your medical insurance plan, and you feel this decision should be reversed. The Plan denied your request. The Plan says your benefits have been coordinated between your medical and dental benefits. This service is not covered by Medicare or by your Dental benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to adjust the copayments for the x-ray exam of the ankle (73610) and the x-ray exam of the foot (73630) provided on August 13, 2021.  You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly 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). Your contract with the Plan clearly says that you must pay a $50 copayment for each Medicare-covered standard x-ray service.     You have been asked to pay $88.30 ($45.64 + $42.66) for the Medicare-covered x-ray services provided.  This includes the Medicare-allowable amount of $45.64 for the x-ray exam of the ankle, which is less than the applicable copayment. Additionally, this includes the Medicare-allowable amount of $42.66 for the x-ray exam of the foot, which is less than the applicable copayment. 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 adjust the copayments for the x-ray exam of the ankle (73610) and the x-ray exam of the foot (73630) provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult daycare services.
You asked the Plan to pre-approve adult daycare services. You say that you are appealing approval for the enrollee to go to adult day care so that she may be able to have some stimulating activities and help with the diagnosis of dementia, Alzheimer's and Parkinson's. The Plan denied your request. The Plan says adult day care is considered custodial level of care and is not covered.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adult daycare services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve adult daycare services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral exam (D0140) provided by a participating provider on July 13, 2021, to August 6, 2021.  You asked the Plan to pay for a limited oral exam. You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says this benefit has already been exhausted.  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 a limited oral exam once every year.  We looked at the file and Medicare rules. Evidence was provided to show that D0140 was provided on March 30, 2021.  Based on this information, we decided that the Plan's rules for coverage of a limited oral exam have already been exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral exam (D0140) provided by a participating provider on July 13, 2021, to August 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services (99291) provided on July 9, 2021.  You asked the Plan to pay for critical care services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the enrollee elected hospice. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on September 27, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 71045 (chest x-ray) and 32555 (thoracentesis). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that the enrollee needs daily physician intervention. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.  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 pay for 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 that on review of the available records the enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehabilitation nursing needs noted in the record. At the current level of function, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach to daily therapy. An IRF admission is not medically necessary based on medical stability and lack of rehabilitation nursing needs. The documentation does not support the necessity for admission to an IRF. The enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting.  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 pay for acute inpatient rehabilitation facility (IRF) admission and services.