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

We decided that the Plan does not have to waive the copayment for fundus photography with interpretation and
report (92250) provided on August 6, 2021.
You asked the Plan to waive the copayment for fundus photography with interpretation and report. The Plan
denied your request. The Plan says the claim processed with the correct copayment.
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 $25
copayment for Vision Care, Out-of-Network Medicare Covered Vision Services.
You have been asked to pay a $25 copayment for fundus photography with interpretation and report. The
fundus photography with interpretation and report falls within the Vision Care, Out-of-Network Medicare
Covered Vision Services 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 fundus photography with interpretation and report (92250)
provided on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental for back pain. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 8, 2021.
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for diagnostic radiology services provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA).
You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation (RFA). You say that the requested lumbar facet joint radiofrequency ablation (RFA) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested lumbar facet joint radiofrequency ablation (RFA) procedure.
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 lumbar facet joint radiofrequency ablation (RFA). Our reviewer says that the enrollee does not meet criteria for the requested lumbar facet joint radiofrequency ablation (RFA) procedure. Our physician reviewer found the previous cervical RFA procedure in November 2020 did not provide any improvement in pain relief on the right. The review has determined that the enrollee does not meet the LCD criteria for the requested repeat of the right C3/C4, C4/5 RFA. The requested procedure is 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 lumbar facet joint radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) provided August 9, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you would like the service covered.
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 every 36 months.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive
exam was previously covered on June 30, 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 August 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the copayment for ambulance services provided on March
11, 2021.
You asked the Plan to pay for the copayment for the ambulance trip. You say that you did not have ambulance
services on that day. 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 $300
copayment per one-way ambulance trip.
The record shows you were transported by ambulance to the hospital on March 11, 2021. Therefore, you have
been asked to pay a $300 copayment for the ambulance trip. Ambulance trips fall within the Ambulance
Services 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 pay for the copayment for ambulance services
provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code(s): 99205 and 99214) to be
provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network office visit. You say that the services are medically
necessary The Plan denied your request. The Plan says there are in-network providers available who can
provide the requested 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested
provider in this case is not a network provider with the Plan. The Plan has network providers available who can
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit
(CPT code(s): 99205 and 99214) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted acute hypoxic respiratory failure due to Coronavirus
pneumonia. The record indicates that the enrollee is improving but still requires acute care services. The
enrollee continues to receive acute care services, and these have not been denied. The medical record does not
indicate that the enrollee requires services that they are not currently receiving but that would be available at
the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be
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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided on April 23,
2021, and July 23, 2021.
You asked the Plan to waive the copayments for the office visits. You say that you are struggling to pay these
bills. You say you feel the copays should be waived since they are due to having COVID. 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 $20
copayment for each primary care physician office visit.
You have been asked to pay a $20 copayment for the office visits. The office visits fall within the
Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for the office visits provided on April 23, 2021, and July 23,2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his poor endurance and the severity of his deconditioning. Care at the skilled nursing facility level appears to be appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections.
You asked the Plan to pre-approve the Keytruda injections. You say that it is felt that this should be covered.
The Plan denied your request. The Plan says there is a lack of support of the use of this drug for the enrollee's
condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Keytruda injections. Our reviewer
says that the requested use of Keytruda is not considered medically reasonable and necessary in this case. Our
physician reviewer found The enrollee is a 62 year old male with a diagnosis of extraskeletal myxoid
chondrosarcoma. Treatment with Keytruda have been requested. This use of Keytruda is not approved by the
FDA for this enrollee's condition. Based on the medical records provided, National Comprehensive Cancer
Network guidelines, and the Medicare-approved major drug compendia, there is no documentation that the
requested use of Keytruda is supported for the enrollee's diagnosis. Based on this information, the requested
use of this drug is not shown to be medically reasonable and 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 Keytruda injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Keytruda (pembrolizumab) injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure for a sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (G0260) provided on May 4, 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 service 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the Medicare-covered surgery provided at an outpatient hospital. 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 injection procedure for a sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography (G0260) provided on May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan (93976-26-XU) provided on May 3, 2021.
You asked the Plan to pay for code 93976-26-XU. 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 supported 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
93976-26-XU is a column II code to column I code 76856. 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 the duplex scan (93976-26-XU) provided on May
3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of impacted tooth - partially bony (D7230)
provided June 7, 2021.
You asked the Plan to pay for the partially bony tooth extraction. You say that you feel you had a simple
extraction, not a bony extraction and it should be covered as such. The Plan denied your request. The Plan says
this service is not covered under your benefits.
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
removal of impacted tooth - partially bony (D7230) provided June 7, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography (CT) abdomen and
pelvis (74176) provided March 1, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that this was for a CT scan and
you assumed it would be covered. The Plan denied your request. The Plan says the claim was processed with
the correct copayment applied per the Evidence of Coverage.
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 $150
copayment for all other diagnostic and nuclear medicine radiological services.
You have been asked to pay $150 copayment for the diagnostic service. The diagnostic service 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 computed tomography (CT) abdomen and pelvis (74176) provided March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
August 4, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the provider did not advise
you that this x-ray would not be covered. The Plan denied your request. The Plan says this is not a covered
service under your 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. The only type of x-rays that are covered under your plan are bitewing
x-rays. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays
(D0210) provided on August 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided April 9,
2021, and August 2, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you would like the
ambulance trips covered. The Plan denied your request. The Plan says you were charged this cost sharing
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for each ambulance trip. You had 2 ambulance trips. The Plan charged you $600 for these services.
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 ambulance services provided April 9, 2021, and August
2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials rendered on December
29, 2020.
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 Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and
clinical staff time over and above those usually included in an office visit or other non-facility service(s), when
performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious
disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan
does not have to pay for the additional supplies and materials rendered on December 29, 2020.