Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SmartPill GI Monitoring System.
You asked the Plan to pre-approve SmartPill GI Monitoring System. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 pre-approve SmartPill GI Monitoring System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee complains of intermittent abdominal bloating and discomfort, and seven to eight years of nausea with episodic vomiting. Evaluation has included esophagogastroduodenoscopy and colonoscopy performed in tandem on October 19, 2020, and gastric emptying scan June 8, 2021. The latter study showed 16% retention at four hours. The enrollee has gastroparesis associated with ongoing narcotic use of Percocet four times daily. The medical necessity of SmartPill analysis is not apparent from available records. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SmartPill GI Monitoring System have not been met. Therefore, we decided that the Plan does not have to pre-approve SmartPill GI Monitoring System.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 19370, 11970, 15771, and 15772 provided on May 7, 2020.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical records. The Plan denied your request. The Plan says these services are all considered inclusive to the approved service coded as 19380.
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 codes 19370, 11970, 15771, and 15772 are:
19370 - Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy 11970 - Replacement of tissue expander with permanent implant 15771 - Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate 15772 - Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) We asked our coder 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 medical services. Our reviewer says that the documentation provided does not support the payment for the services as billed. Our reviewer found the medical records provided does not include sufficient documentation to validate these procedures were performed as separate, distinct procedures, separate from 19380. Therefore, these procedures are not eligible for separate reimbursement. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 19370, 11970, 15771, and 15772 provided on May 7, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 7, 2021, through June 10, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was medically necessary. The Plan denied your request. The Plan says that based on the information received, it does not support an acute inpatient stay.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the record indicates that the enrollee, with a history of significant dementia, was brought to the emergency department by advanced life support ambulance after two syncopal episodes and found to be tachypneic and hypotensive with an elevated white blood cell count. The record is sufficient to determine that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The elements of the coverage rule are satisfied. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 7, 2021, through June 10, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on September 14, 2020.
You asked the Plan to pay for the resin-based composites. You say that the dentist informed you your insurance
went through, but you found out he was not in-network. You say that you are being billed for services he did
not do and would like this investigated. The Plan denied your request. The Plan says there is no coverage for
services rendered by an out-of-network provider.
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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resinbased
composites provided on September 14, 2020.
Your complaint about the dentist running a scam on senior citizens 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test and fluoride varnish
application provided on June 3, 2021.

You asked the Plan to pay for the adjunctive pre-diagnostic test and fluoride varnish application. You say that
you found this office online as an approved provider and confirmed they were plan providers. The Plan denied
your request. The Plan says the claim reprocessed as a one-time exception to cover services toward your in-network
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 adjunctive pre-diagnostic test and
fluoride varnish application are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for the adjunctive pre-diagnostic test and fluoride varnish application provided on
June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded as 99204 provided on February 12, 2021
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier was not billed with this service as required by Medicare rules.
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 99204
is a column II code to column I code 93016. 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 office visit coded as 99204 provided on February 12, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography scan (70450) provided on January
20, 2021.
You asked the Plan to pay for code 70450. 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 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 the computed tomography scan (70450) provided on January 20,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.
You asked the Plan to pre-approve Benlysta. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Benlysta. Our reviewer says that the
documentation does not support that the requested drug, Benlysta is medically reasonable or necessary. Our
physician reviewer found the enrollee has a diagnosis of discoid lupus erythematosus and is anti double strand
DNA antibody negative with normal C3 and C4, erythrocyte sedimentation rate, and c-reactive protein test
levels. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied.
Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Benlysta have not been met. Therefore, we decided that the Plan does not have
to pre-approve Benlysta.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory pathogen screening panel (87496, 87498,
87532, 87541, 87634, 87640, 87798) provided on May 11, 2021.
You asked the Plan to pay for a respiratory pathogen screening panel. You say that this testing was ordered by the physician. The Plan denied your request. The Plan says this is not covered screening testing.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a respiratory pathogen screening panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a respiratory pathogen screening panel (87496, 87498, 87532, 87541, 87634, 87640, 87798) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint
rendered on May 21, 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 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 these services. Our reviewer says that the
services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She
had diagnostic bilateral SI joint injections on April 2, 2021, and achieved 90 percent pain relief for one and a
half weeks. She had RFA of the lateral sacral branches bilaterally on May 21, 2021. The RFA of the SI joint is
considered experimental/investigational in nature due to wide variation in efficacy. The services were not
reasonable or 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 pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint rendered on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the outof-
network (OON) provider on March 16, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the 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 laboratory services (88305, 88312) rendered by the out-of-network (OON) provider on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on March 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the surgical pathology services. You say that the enrollee was seen by a network physician, however, there were no in-network laboratories able to provide the appropriate medical care. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided on March 3, 2021, by an out-of-network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99349) rendered by the out-of-network (OON) provider on June 17, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transfer bench and related costs provided June 14, 2021.
You asked the Plan to pay for the transfer bench. You say that you would like to be reimbursed for this equipment. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the transfer bench and related costs provided June 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99203)
rendered on May 4, 2021.

You asked the Plan to waive the copayment for an office visit with a specialist. You say that you were charged
two copayments for May 4, 2021. You also say that per your phone call to the plan, you were only responsible
for one copayment for each appointment. You also state that your bill does not show the other charges for May
4, 2021. The Plan denied your request. The Plan says you were charged the correct copayment 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 $45
copayment for a specialist's office visit.

You have been asked to pay a $45 copayment for an office visit with a specialist. The record does not show
more than one copayment was charged for an office visit with a specialist on May 4, 2021. 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 office visit with a specialist (99203) rendered on May 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on May 20, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that you attached medical records to
show the medical necessity and the physician is correct on the claim. You say that the claim should be
reconsidered. The Plan denied your request. The Plan says the non-participating facility billed an outpatient
hemodialysis treatment for an ESRD patient without billing the appropriate 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. Medicare rules also say that Medicare does not
allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS,
when furnished to ESRD patients in the outpatient department of a hospital.
We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare
criteria for coverage of the outpatient hospital services have not been met. Specifically, the submitted claim
does not include the required CPT code to indicate that the member had non-routine dialysis treatments in the
outpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of the
outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the
outpatient hospital services provided on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (85060, 88184, 88185, 88189) rendered by the out-of-network (OON) provider on July 5, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 laboratory services (85060, 88184, 88185, 88189) rendered by the out-of-network (OON) provider on July 5, 2021.