Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia service (99100) provided on September 10, 2021.

You asked the Plan to pay for anesthesia service. You say that this was billed correctly. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99100 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia service (99100) provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 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 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 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the requested device 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 pre-approve a MyoPro Motion G Orthotic device.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the enrollee has a past medical history of diabetes and a stroke with left
upper extremity weakness. There is no documentation that the MyoPro Motion G Orthotic device at issue in
this case meets Medicare criteria for medically reasonable and necessary. Current clinical guidelines designate
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise
therapies" with unproven benefit in the home environment. In addition, provided records report the enrollee has
a left shoulder subluxation which may be a contraindication to use of the device. Therefore, the enrollee does
not meet criteria for the requested device.
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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110)
provided on July 20, 2021.
You asked the Plan to reimburse you for the dental services. You say that you were advised that the claim was
denied because the provider would not accept Medicare funds. You also say this should not matter. The Plan
denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that
payment cannot be made to a dentist that has opted out of Medicare.
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 Evidence of Coverage clearly
states that if you use a provider that has opted out of Medicare you will not receive reimbursement. Therefore,
we decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110)
provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on August 6, 2020.
You asked the Plan to pay for the dental service. You say that this service was required to treat an abscessed
tooth. The Plan denied your request. The Plan says extraction is not listed as a covered dental 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7140)
provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on June 14, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you went to the office visit to get a coronavirus (COVID-19) test. The Plan denied your request. The Plan says the office visit for a COVID-19 test was preprocedural related and the proper copayment was applied.

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 $35 copayment for services obtained from a specialist in a specialist's office. The total amount allowed was $21.83 which is lower than the copayment amount of $35.

You have been asked to pay a $21.83 copayment for an office visit. An office visit falls 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 copayment for an office visit provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 10, 2021, to April 16, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment per day for days 1-5 for Inpatient Hospital Care.

You have been asked to pay a $1,950 copayment for five days of inpatient hospital care ($390 x 5 = $1,950). 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 inpatient hospital care provided from April 10, 2021, to April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection 1mg (J0897) provided on July 29, 2021.

You asked the Plan to waive the coinsurance for the denosumab injection. You say that the services should be covered since your previous health plan covered them. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B Prescription Drugs.

You have been asked to pay a 20% coinsurance for a denosumab injection (the allowed amount is $1,205.40 x 20% = $241.08). Denosumab injections fall within the Medicare Part B Prescription Drugs 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 coinsurance for a denosumab injection 1mg (J0897) provided on July 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003)
provided on December 23, 2020.
You asked the Plan to pay for the infectious agent detection. 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 enrollee's terminal condition.
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 the infectious agent detection by nucleic acid (U0003)
provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00537) provided September 1, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The
Plan denied your request. The Plan says payment for this service is included in payment for the primary
procedure.
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 CPT code 00537 is not supported in the medical record. Specifically, payment for the anesthesia
service is bundled in payment for the primary procedure. The code billed is not separately payable. Based on
this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for anesthesia services (00537) provided September 1,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D, 25 hydroxy, includes fraction(s), if performed (82306) provided July 13, 2021.

You asked the Plan to pay for the screening testing services. You say that please review medical records and reconsider the charges billed. The Plan denied your request. The Plan says 82306 is not a Medicare benefit for the diagnosis listed on the claim and is done for screening purposes. Screening tests without a valid medical diagnosis related to the health of the patient is not a benefit.

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, the screening testing services, 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 vitamin D, 25 hydroxy, includes fraction(s), if performed (82306) provided July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Minuteman procedure.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the clinical value and effectiveness of the Minuteman procedure in
the setting of lumbar spinal stenosis have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The minuteman
procedure is experimental. More research is needed to show safety and efficacy of the minuteman device. Our
physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Minuteman procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections can be covered if the
LCD criteria are met.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. You have not had an
adequate trial of conservative therapy. Our physician reviewer found that your condition does not meet
Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve epidural steroid injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on October 11, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are being charged $450 for an ambulance visit even though you never went to the hospital. You also say that you did not care for the ambulance providers, they were only there for 5 to 10 minutes, did not do much, and you do not feel you should have to pay for this. The Plan denied your request. The Plan says this service is not covered.

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 October 11, 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 with no transport (A0998) provided on October 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on
March 21, 2021.
You asked the Plan to pay for the hospital discharge day management. You say that you would like this claim
to be reconsidered for payment. 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 enrollee's terminal
condition.
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 the hospital discharge day management (99239) provided on
March 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic screening testing provided on May 14, 2021.

You asked the Plan to pay for the molecular genetic screening testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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. 

Review of the file does not include results of a prior prostate biopsy. There was no documented significant interval increase in prostate-specific antigen level. This means that the molecular genetic screening testing at issue in this appeal 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 molecular genetic screening testing provided on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee arthroplasty (TKA) for the enrollee.
You asked the Plan to pre-approve these services. You say that other treatment options would not be enough to
treat the enrollee's level of pain and functionality. The Plan denied your request. The Plan says that the records
show the enrollee does not have advanced joint disease and has not had three months of non-surgical medical
management or records demonstrating why this is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that TKA can be covered if LCD criteria have been
met.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The enrollee was
being treated for tear of medial meniscus; right knee osteoarthritis. He presented with right knee pain that
began on January 13, 2022, from an injury while playing pickleball. He feels the symptoms are improving, but
still has a fair amount of pain. Body mass index is 33. Exam of the right knee reveals satisfactory range of
motion of the knee with crepitation noted. No significant joint effusion is noted. Knee is stable to varus and
valgus stress. There is moderate patellofemoral crepitation with range of motion of the knee. He has had an
aspiration and was provided with a knee brace on January 13, 2022. Magnetic resonance imaging demonstrates
a meniscal tear, moderate medial compartment arthrosis, and mild to moderate patellofemoral compartment
cartilage loss. However, detailed documentation is not evident regarding trial and failure of recent, reasonable
and comprehensive less invasive conservative care measures. There are limited large-scale, long-term
references showing the safety and efficacy of the requested surgery without a trial and failure of reasonable and
recent/comprehensive conservative measures prior. There is no compelling rationale presented or extenuating
circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve total knee arthroplasty (TKA) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the alginate dressing (A6196), foam dressing (A6212), gauze (A6219 and A6222), and absorptive dressing (A6252) provided on December 14, 2020.
You asked the Plan to pay for the alginate dressing, foam dressing, gauze, and absorptive dressing. You say that the physician provided medically necessary services to the enrollee in good faith. You also say that the provider is seeking correct reimbursement. 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 enrollee's terminal condition.
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 the alginate dressing (A6196), foam dressing (A6212), gauze (A6219 and A6222), and absorptive dressing (A6252) provided on December 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on
October 22, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that the provider rendered
medically necessary services to the enrollee in good faith, and the rendered services meet professionally
recognized standards of healthcare. 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 enrollee's terminal
condition.
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 the subsequent nursing facility care (99308) provided on
October 22, 2020.