Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve two of the requested dental implants. We decided that the Plan does not have to pre-approve the two additional dental implants.
You asked the Plan to pre-approve two of the requested dental implants. You say that this is necessary for the enrollee as she is not able to consume sufficient calories due to ill-fitting dentures.
Plan says that these services are purely dental in nature and cannot be covered by Medicare. Review of the enrollee's Evidence of Coverage for the calendar Year 2021 does not document coverage for any enhanced dental benefits.
We decided that the Plan has to pre-approve two dental implants.
Medicare does not generally provide coverage for dental services. However, the Plan offers a supplemental dental benefit that covers up to two dental implants per year. In this case, the Plan has incorrectly stated that the enrollee does not have an enhanced dental benefit. Although the services were requested with a medical code, coverage under the Plan exists for two dental implants. These can be covered when billed with the proper dental codes. We find that the Plan is required to issue authorization for the covered implants. Therefore, we decided that the Plan has to pre-approve two dental implants.
We also decided that the Plan does not have to pre-approve the two additional dental implants.
Medicare does not generally provide coverage for dental services. However, the Plan offers a supplemental dental benefit that covers up to two dental implants per year. Since these services are not considered medical in nature, since implants are the replacement of teeth, they cannot be covered by Medicare. The dental benefit offered by the Plan is not required to cover more than two implants per year. As such, the other two implants being requested are not covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve the two additional dental implants.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Genesight Psychotropic testing (81479) provided on March 4, 2021.
You asked the Plan to pay for the Genesight Psychotropic testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this testing is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the present evidence does not clearly demonstrate that routine PGx testing for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Genesight Psychotropic testing have not been met. Specifically, present evidence does not clearly demonstrate that this method of testing offers a benefit over contemporary evidence-based medication selection protocols. Therefore, we decided that the Plan does not have to pay for the Genesight Psychotropic testing (81479) provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block provided on April 28, 2021.
You asked the Plan to pay for the nerve block. The Plan denied your request. The Plan says this is not medically necessary.
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 nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 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 nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on May 24, 2021.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because
this testing is a medically necessary Medicare-covered benefit. The Plan denied your request. The Plan says the
Guardant360 panel must be billed with 81479.

The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report
Guardant360 testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Guardant360 testing have not been met. Specifically, the claim was billed as a panel of codes.
Guardant360 testing must be billed with one unit of CPT code 81479. Therefore, we decided that the Plan does
not have to pay for Guardant360 testing provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following the laparoscopy, surgical; partial nephrectomy (CPT code 50543).
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested procedure is not on the approved inpatient list. Therefore, the full admission is not approved. The Plan states the Health Plan will consider adjusting the admission from observation to inpatient if criteria are met and severity of illness and intensity of service are met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that you are scheduled for a laparoscopic partial nephrectomy. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning two (2) or more midnights. You may be admitted for observation. The elements of the coverage rule are not satisfied. The requested service is not 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care following the laparoscopy, surgical; partial nephrectomy (CPT code 50543).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from June 15,
2021, to June 22, 2021.
You asked the Plan to pay for out of network services. You say that these services should be covered the Plan.
The Plan denied your request. The Plan says you 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 by
Angelo Pulgiano from June 15, 2021, to June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the selective spinal angiograms provided during a vascular embolization procedure (37243) on March 8, 2021, billed with 18 units of 75705-26-59.
You asked the Plan to pay for the selective spinal angiograms as billed. You say that the services billed should be paid in full. The Plan denied your request. The Plan says these services are not separately payable in addition to 37243.
The Plan must follow Medicare rules. The rules state that for NCCI edits with a modifier indicator of 1, payment can only be made for the Column 2 code if a clinically appropriate modifier is used. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. Code 75705 is a Column 2 code in relation to code 37243. This code pair has a modifier indicator of 1, meaning that payment can be made for 75705 only if the reported modifier is clinically appropriate. 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 selective spinal angiograms as billed Our reviewer says that the use of modifier -59 for this code is not supported. Our physician reviewer found the documentation does not support that this modifier is being used to report a separate procedure. 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 selective spinal angiograms as billed have not been met. Therefore, we decided that the Plan does not have to pay for the selective spinal angiograms provided during a vascular embolization procedure (37243) on March 8, 2021, billed with 18 units of 75705-26-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
You asked the Plan to reimburse you for a health club membership. You say that you tried to go to the facility to get a printout of your receipt but due to Coronavirus, the facility was closed. You also say that you have submitted receipts for several years prior and you have never been this late and should be reimbursed. The Plan denied your request. The Plan says reimbursements must be received by March 31st of the following year.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility. Reimbursement requests must be received by the Plan no later than March 31st of the following year.
The Plan's rules for coverage of gym benefits have not been met. The records show that you submitted your reimbursement request on June 1, 2021. The EOC confirms that a request for reimbursement must be received by the Plan no later than March 31st of the following year. Please note, the Plan contract allows you to submit a photocopy of a cancelled check written to the facility, a class, or a credit card statement as proof of payment instead of the facility receipt. Therefore, we decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided on October 21, 2019.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says prior authorization was required and not 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 SNF services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for SNF services provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and urinalysis provided on June 9, 2021, by
an out-of-network provider.
You asked the Plan to pay for the office visit (99213) and urinalysis (81000). You say that the enrollee needs
continuity of care. The Plan denied your request. The Plan says the services were not urgent, emergent or
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the office visit and urinalysis provided on June 9, 2021, by an
out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services represented by code 71045 provided on May 19, 2021.

You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 has a bundled relationship with code 71101 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services represented by code 71045 provided on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on January 5,
2021.
You asked the Plan to pay for the paramedic intercept. You say that you feel you should not have to pay for this
because it was an emergency and the enrollee needed a paramedic to ridge to the hospital with her. The Plan
denied your request. The Plan says the two ambulance companies do not have a contract, and no payment can
be made.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the
paramedic intercept (A0432) provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view
(D0380) provided on May 3, 2021.
You asked the Plan to pay for the cone beam CT image capture. You say that this service was provided after
your optional dental coverage began. The Plan denied your request. The Plan says oral pathology procedures
are not covered under your dental plan.
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 cone
beam CT image capture with limited field of view (D0380) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious pathogen detection by nucleic acid for various organisms provided on April 8, 2021, billed with 9 codes for each pathogen tested.
You asked the Plan to pay for the lab testing as billed. You say that this testing was ordered by the treating physician to determine the cause of the patient's condition. The Plan denied your request. The Plan says the documentation does not support the codes 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. We find that the CPT codes billed on this claim are not supported in the medical record. Specifically, the lab report only indicates results for pathogen categories and does not provide evidence of testing of each of the specific pathogens that are billed on this claim. Based on this information, we decided that Medicare rules for coverage of the lab testing as billed have not been met. Therefore, we decided that the Plan does not have to
pay for the infectious pathogen detection by nucleic acid for various organisms provided on April 8, 2021, billed with 9 codes for each pathogen tested.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care services rendered on June 4, 2020.
You asked the Plan to waive the copayment for these services. You say that the claim was incorrectly processed. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for primary care physician (PCP) services (including Medicare-covered telehealth and urgently needed services).
Review of the file shows that you the enrollee received primary care services on June 4, 2020. The Plan originally processed a specialist copayment; however, the claim was reprocessed as a primary care visit. The enrollee has been asked to pay a $35 copayment for these services. These services fall within the primary care physician (PCP) services (including Medicare-covered telehealth and urgently needed services) 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 copayment for the wound care services rendered on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on May 21, 2021, by an out of network provider.

You asked the Plan to pay an additional amount for the dental services. You say that you switched dental offices. You say that this office is closer to you. You say that the services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years. The Plan says that the frequency limit has been exceeded. The Plan says that if you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan also says you are responsible for the difference between the INFS and dentists' charged fees.

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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on July 28, 2020. Additionally, the record shows that the Plan paid the out of network cost share for the bitewing x-ray. You are responsible for the difference between the INFS and dentists' charged fees. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on May 21, 2021, by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for spinal surgery services provided on February 8, 2021.

You asked the Plan to waive the copayment for the spinal surgery services. You say that you feel that you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received spinal surgery in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $295 copayment for all other Outpatient Services not provided in an Ambulatory Surgical Center.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received spinal surgery on February 8, 2021 provided in an outpatient hospital setting. You have been asked to pay a $295 copayment for the spinal surgery services. The spinal surgery services fall within the Outpatient surgery 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 spinal surgery services provided on February 8, 2021.