Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that this has helped you in the past. The Plan denied your request. The Plan says that this is only supported once.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the requested use of Zilretta is medically reasonable and necessary. Our physician reviewer found Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. The product label does not preclude use of the drug more than one time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve Zilretta.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 8, 2021.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 subsequent nursing facility care provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin B-12 testing rendered on December 15, 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 covered.

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 Vitamin B-12 assay, 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 the Vitamin B-12 testing rendered on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx for Prostate Cancer testing rendered on April 5, 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 testing is not covered.

The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests. 

We looked at the file and Medicare rules. The SelectMDx for Prostate Cancer test was not approved through the MolDX program for the date of service at issue. 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 SelectMDx for Prostate Cancer testing rendered on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on March 30, 2021.

You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you shouldn't have to pay more than your $45 copay for an office visit. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $50 copayment for outpatient diagnostic testing. 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 outpatient diagnostic testing provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), bitewing x-rays
(D0274) and periapical x-ray (D0220) provided on June 21, 2021.
You asked the Plan to pay for the dental services. You say that you were advised that the provider in this case
was on the list for your Dental Plan. You say that you are now being told it is not covered because you have
Medicare. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan
also says that dental services received out-of-network are not covered.
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 dental services you received are not
among those covered under this benefit when performed out of network. Therefore, we decided that the Plan
does not have to pay for the oral exam (D0120), cleaning (D1110), bitewing x-rays (D0274) and periapical xray
(D0220) provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not
covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as
not reasonable and necessary.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services code 99233 provided 
on May 12, 2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 99233 
for the subsequent hospital care services is a column II code to column I code 99222. 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 subsequent hospital care 
services code 99233 provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the posterior tibial neurostimulation
procedure you had at an outpatient hospital facility on July 16, 2021, through August 10, 2021.

You asked the Plan to reduce the copayment for the posterior tibial neurostimulation procedure. You say that
you have had this procedure done in the past and you did not have to pay the outpatient surgery copayment.
You said that you only had to pay a $40 copayment. The Plan denied your request. The Plan says you were
charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($318.21)
is less than your copayment obligation, you are responsible for the full allowed 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 $350
copayment for outpatient surgery and services at an outpatient hospital facility.

You have been asked to pay a $350 copayment for the posterior tibial neurostimulation procedure. The
posterior tibial neurostimulation procedure falls within the outpatient surgery and services at an outpatient
hospital facility 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 reduce the copayment for the posterior tibial
neurostimulation procedure you had at an outpatient hospital facility on July 16, 2021, through August 10,
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90791 and 90837) provided on March 3, 2021, through March 31, 2021.

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because these services are medically necessary and should be covered during the public health emergency. The Plan denied your request. The Plan says telehealth services must be rendered by an in-network provider.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Advantage (MA) plan furnishing additional telehealth benefits may only do so using contracted providers. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, the record indicates that this service was rendered by an out-of-network provider. Telehealth services can be covered when rendered by in-network providers. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90791 and 90837) provided on March 3, 2021, through March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cool Sculpting procedure.
You asked the Plan to pre-approve a Cool Sculpting procedure. You say that you need this because you cannot sleep and are in pain. The Plan denied your request. The Plan says this is cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 a Cool Sculpting procedure. Our reviewer says that the requested procedure is not medically necessary. Our reviewer found the record indicates that the requested procedure is to assist in weight loss and chronic medical condition management. The requested service is not credibly for the repair of accidental injury or to improve the functioning of a malformed body member. The requested procedure is cosmetic in nature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Cool Sculpting procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cool Sculpting procedure.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on January 26, 2021.
You asked the Plan to pay for the subsequent hospital care. You say that the claim denied as patient enrolled in hospice and are resubmitting the claim with a letter from the payer attached. You say that payment should be reviewed. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 11, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 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 procedure code 81455 is not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code
81455 are denied as not medically necessary.
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighty (80) additional routine transportation trips.
You asked the Plan to pre-approve eighty (80) additional routine transportation trips. You say that you need transportation to chemotherapy appointments. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty (30) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan does not have to cover routine transportation above the benefit maximum of thirty (30) routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve eighty (80) additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement (11721) rendered by the out-of-network (OON) provider on April 15, 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 nail debridement (11721) rendered by the out-of-network (OON) provider on
April 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper gastrointestinal endoscopy (43249) provided on June 16, 2021.
You asked the Plan to waive the copayment for the endoscopy. You say that you thought your plan did not require copayments or coinsurance for any services. The Plan denied your request. The Plan says the copayment for this service was applied correctly in accordance with your contract.
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 $275 copayment for outpatient surgery services provided in a hospital setting. You have been asked to pay a $275 copayment for the endoscopy. The endoscopy is classified as a surgical procedure and was provided in an outpatient hospital setting. 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 upper gastrointestinal endoscopy (43249) provided on June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) 
provided on March 10, 2021. 

You asked the Plan to pay for the ambulance response without transport. You say that you felt better after
treatment and did not feel you needed to go to the hospital. You feel this service should be covered as it was
medically necessary. The Plan denied your request. The Plan says the ambulance benefit is a transportation
benefit. Without transport, there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on March 10, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without
transport (A0998) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital visits: initial and subsequent (99222)
provided April 25, 2021.
You asked the Plan to pay for the hospital services. You say that you disagree with this decision. According to
coding guidelines, the procedures billed do not meet the criteria for bundling. Please find attached the progress
notes supporting this claim. The Plan denied your request. The Plan says the benefit for this service is included
in the payment/allowance for another service/procedure that has already been adjudicated.
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 find that CPT code 99222 is not supported in the medical record. Specifically, this service is
included with the critical care evaluation and management service (99291) billed on the same date of service by
another provider. Both providers are within the same group and ha the same specialty. Based on this
information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore,
we decided that the Plan does not have to pay for the inpatient hospital visits: initial and subsequent (99222)
provided April 25, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee replacement (27447).
You asked the Plan to pre-approve the total knee replacement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says a failed trial of conservative treatment is required before surgical treatment can be considered.
The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty is covered when there is unsuccessful non-surgical medical management for a minimum of at least 3 months. 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 total knee replacement. Our
reviewer says that the requested procedure is not medically necessary. Our physician reviewer found there is no
supportive documentation provided that corroborates that reasonable, recent, and comprehensive conservative
care has been tried and failed. There is no compelling rationale presented or extenuating circumstances noted to
support the medical necessity of this request as an exception.
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 total knee replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve a total knee replacement (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit services (99349) provided
on March 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit services. You say that you are resubmitting the claim with
supporting documentation to support CPT code 99349. Please review and reprocess for payment. The Plan
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers
require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the established patient home visit services (99349)
provided on March 30, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 3, 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 were not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 3, 2021.