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

 We decided that the Plan does not have to pay for the pelvis x-ray (72170) provided on September 4, 2021.  You asked the Plan to pay for the pelvis x-ray. You say that this date of service is after the termination of the enrollee's Hospice period and should be covered. 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. 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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 September 3, 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 pelvis x-ray (72170) provided on September 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crowns (D6060 x 2) provided on July 30, 2021.  You asked the Plan to pay for the dental services. You say that you requested your doctor send the proper paperwork to your plan. The Plan denied your request. The Plan says abutment supported porcelain fused to metal crowns are not listed as covered services.  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 abutment supported porcelain fused to metal crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crowns (D6060 x 2) provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a humate-p injection provided on July 19, 2021.  You asked the Plan to waive the coinsurance for the injection. You say that you feel the charger are higher than allowed. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Part B drugs, including injectable drugs.      You have been asked to pay $823.83, which is 20% of the allowed amount for the drug ($4119.17 allowed amount x 20% coinsurance = $823.83). You have also been asked to pay $50.27, which is 20% of the allowed amount for the drug administration ($251.36 allowed amount x 20% coinsurance = $50.27). The injection falls 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 humate-p injection provided on July 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram (ECG) (93010) and emergency department (ED) visit (99285) provided on November 6, 2020.  You asked the Plan to pay for the ECG and ED visit. 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 electrocardiogram (ECG) (93010) and emergency department (ED) visit (99285) provided on November 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation indicating any spinal compression fractures.  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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support the need for kyphoplasty. The imaging studies do not show acute compression fractures of the spine.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve Intensity modulated radiation therapy (IMRT).  You asked the Plan to pre-approve IMRT services. You say that the clinical information provided supports the need for the requested services. The Plan denied your request. The Plan says that there is no current research showing that the enrollee's type of cancer responds better to the requested type of treatment than three-dimensional (3D) conformal radiation therapy. The Plan says that only weekly picture studies are needed.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 IMRT services. Our reviewer says that IMRT services are considered medically reasonable and necessary in this case. Our physician reviewer found IMRT can be considered medically necessary when a clinically meaningful reduction in normal tissue dose exposure can be achieved. For this case, IMRT would be furnished in accordance with accepted standards of care given the enrollee's very high body mass index (BMI), and a plan comparison showing an unacceptable 3D plan.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT services have been met. Therefore, we decided that the Plan has to pre-approve Intensity modulated radiation therapy (IMRT).   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the computed tomography of the thorax,
diagnostic; with contrast material (71260) provided on September 21, 2021.
You asked the Plan to adjust 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 $225
copayment for each Medicare-covered advanced radiology service.
You have been asked to pay $177.66 for the Medicare-covered advanced radiology service provided. This is
the Plan's allowed amount for this service which is less than the applicable copayment.
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 adjust the copayment for the computed tomography of the thorax, diagnostic; with
contrast material (71260) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (12032) provided on June 7, 2021.

You asked the Plan to pay for code 12032. 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 12032 is a column II code to column I code 11102. 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 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (12032) provided on June 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998)
provided on September 14, 2021.
You asked the Plan to pay for the ambulance service. You say that you feel that you were persuaded into not
going to the hospital. The Plan denied your request. The Plan says there was not transport provided on the date
of service in this case. The Plan also says that since there was no transport provided, 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 September 14, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Additionally, the record shows that you signed a refusal of transport on this date of service. Therefore, we
decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998)
provided on September 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0999)
provided on June 17, 2021.
You asked the Plan to pay for the ambulance service. You say that you had no choice but to contact 911. You
also say that you have contacted 911 in the past to be helped up and it was covered. The Plan denied your
request. The Plan says ambulance transportation is covered only when you are actually transported by
ambulance. The Plan also says that since you were not transported by this ambulance, the service is not covered
under your plan.
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 June 17, 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, no
transport, (A0999) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery performed on August
31, 2021.

You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you have Medicare and
Medicaid and you do not owe any extra costs. The Plan denied your request. The Plan says the correct
coinsurance 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 20%
coinsurance for surgery at an outpatient hospital.

You have been asked to pay $583.40, which is 20% of the allowed amount for the outpatient surgery ($2916.98
allowed amount x 20% coinsurance = $583.40). The outpatient surgery falls within the Outpatient Surgery and
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgery performed on August 31,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on August 2, 2021.
You asked the Plan to pay for the endodontic therapy. You say that the enrollee was advised at the appointment
that their portion of the procedure would be $595.40 and their insurance would pick up the balance of $627.00.
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The
Plan also says that the enrollee did not contact the Plan prior to this date of service to verify benefits and
provider eligibility.
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
endodontic therapy (D3310) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (64445) provided August 17, 2021.
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The
Plan denied your request. The Plan says the billed code is 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.
We find that CPT code 64445 is not supported in the medical record. Specifically, this procedure is included in
procedure code 01480. The records do not support the use of modifier 59. 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 (64445) provided August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the three additional intraoral periapical x-rays (D0230 x3) provided on August 27, 2021.  You asked the Plan to pay for the additional intraoral periapical x-rays. You say that according to the information provided by the Plan, the dental services covered by your plan include preventive and diagnostic services which should include dental x-rays, exams, cleaning, and fluoride. You also say that you believe the x-ray charges should be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three additional intraoral periapical x-rays (D0230 x3) provided on August 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from
rehabilitation before going home. The Plan denied your request. The Plan says this request is not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 the SNF admission. Our reviewer says
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled
nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve a skilled nursing facility (SNF) admission.
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 this is medically necessary. The Plan denied your
request. The Plan says the enrollee's needs do not require an intensive team approach and can be met in an
alternate level of care.
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 the enrollee does not require the intensity of services provided at the IRF.
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the FM/a test provided on November 18, 2020.  You asked the Plan to pay for the FM/a test. The Plan denied your request. The Plan says this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the FM/a test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this new type of testing appears to be promising in more accurately diagnosing fibromyalgia, however, it has not yet been proven to lead to improved outcomes compared to standard diagnostics which are based on clinical symptomatic criteria. Symptoms treatments are the only currently available treatments for this condition at this time. Therefore, without sufficient supportive evidence available, this request for FM/a testing will not be considered medically reasonable or necessary at this 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 the FM/a test have not been met. Therefore, we decided that the Plan does not have to pay for the FM/a test provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on July 11, 2021.

You asked the Plan to pay for code 99153. 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. 

We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on July 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the revision of the Iris (66761) rendered by the out-of-network (OON) provider on October 12, 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 office visit (99214) and the revision of the Iris (66761) rendered by the out-of-network (OON) provider on October 12, 2021.