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

 We decided that the Plan does not have to waive the coinsurance for Medicare-covered Part B drug, Injection, aflibercept, (Eylea, Regeneron) provided on March 26, 2021, and April 23, 2021.  You asked the Plan to waive the coinsurance for Medicare-covered Part B drug, Injection, aflibercept,  (Eylea, Regeneron). The Plan denied your request. The Plan says per your benefits in the 2021 Evidence of Coverage, there is a 20% coinsurance for each Medicare-covered Part B drug.   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 20% coinsurance for Medicare Part B Prescription Drugs.     You have been asked to pay 20% coinsurance for Medicare-covered Part B drug, Injection, aflibercept,  (Eylea, Regeneron). The Medicare-covered Part B drug, Injection, aflibercept, (Eylea, Regeneron) 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 Medicare-covered Part B drug, Injection, aflibercept, (Eylea, Regeneron) provided on March 26, 2021, and April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on October 4, 2021.  You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not include any clinical information to verify if the services rendered were medically necessary.  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 62320 is not supported in the record. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 15, 2021.  You asked the Plan to pay for the laboratory services. 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.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmological services, medical examination and evaluation provided on October 15, 2021.  You asked the Plan to waive the copayment for ophthalmological services, medical examination and evaluation. You say that you attended a diagnostic follow up exam due to a misdiagnosis and you do not feel you should be responsible for the copay. The Plan denied your request. The Plan says the claim processed correctly according to your benefits.  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 $30 copayment for Vision Care, exams to diagnose and treat diseases and conditions of the eye.   You have been asked to pay a $30 copayment for ophthalmological services, medical examination and evaluation. The ophthalmological services, medical examination and evaluation falls within the Vision Care, exams to diagnose and treat diseases and conditions of the eye 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 ophthalmological services, medical examination and evaluation provided by on October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda (J9271).  You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says this medication is not supported for the enrollee's condition.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that Keytruda is not medically necessary. Our physician reviewer found the single agent use of Keytruda for the enrollee's diagnosis of squamous cell carcinoma of the cervical esophagus with no defined PD-L1 status is not indicated, supported, or recommended in any of the compendia.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: ER
Decision: Unfavorable

We decided the Plan does not have to pay for emergency room services provided on July 25, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says procedure code 99285, Emergency department visit for the evaluation and management of a patient. The Plan states this claim denied because it is bundled to another service billed on the same day, under the same code with the same provider and specialty. Per Medicare Claims Processing Manual Chapter 12 Section 30.6.5, Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.

If more than one evaluation and management (face-to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Two claims were billed by the same billing group provider under the same NPI number. Both claims were rendered by providers with a specialty of emergency medicine on the same date of service. Therefore, this second claim cannot paid.

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for emergency room services provided to the enrollee on July 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement partial dentures.  You asked the Plan to pre-approve replacement partial dentures. You say that you visited a dental facility over a year ago because your front teeth were decaying, and the dentist said a partial would fit. You say you had to send the dentures back many times and the last time you went for a visit, the dentures fell out when you got to your car. You also say you have not been able to use the partial dentures, so you visited another provider. The Plan denied your request. The Plan says your current dentures are less than 60 months old, therefore, replacement dentures are not a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers replacement partial dentures every 60 months.   We looked at this physician's review, the file, and Medicare rules. The records show that you received a partial upper denture on May 17, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of replacement partial dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement partial dentures.   Your complaint about your partial upper dentures falling out 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for arthroscopic procedures (29999) provided on February 17, 2021.  You asked the Plan to pay for arthroscopic procedures. You say that this was billed correctly. The Plan denied your request. The Plan says this code is not supported.  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 code 29999 is unlisted procedure, arthroscopy.  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 arthroscopic procedures. Our reviewer says that the billed code is not supported. Our reviewer found the operative report does not describe what the procedures, the unlisted procedure codes are being reported for. While a letter states that 29999 is being reported for arthroscopic capsular release and arthroscopic humeral head chrondroplasty and microfracture, these procedures would be included in the separately billed extensive debridement.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthroscopic procedures have not been met. Therefore, we decided that the Plan does not have to pay for arthroscopic procedures (29999) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve facet joint injections.. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Medicare criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that facet joint injections are subject to the criteria listed 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 facet joint injections. Our reviewer says that the requested facet joint injection services are not medically reasonable and necessary. Our physician reviewer found the enrollee has radiculopathy, has not completed 3 months of conservative therapy, and there is no documentation indicating that the facet joint is the likely cause of pain, without other sources having been ruled out.  The review has determined that the documentation does not support that the coverage criteria for facet joint injections have been met.  The requested facet joint injections are not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections. have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to adjust the coinsurance for the hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323) provided on June 29, 2021.  You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the Medicare Part B drug 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 20% of the cost for Medicare-Part B covered chemotherapy drugs and other Medicare Part B covered drugs.   You have been asked to pay $428.31 (Plan allowed amount of $2,141.55 x 20% coinsurance) for the Medicare Part B drug injection provided. 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 coinsurance for the hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323) provided on June 29, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction (27762-59) provided on April 6, 2021.  You asked the Plan to pay for code 27762-59. You say that the medical records support the billing of modifier -59 with code 27762 provided on April 6, 2021. The Plan denied your request. The Plan says that the medical records do not support the billing of modifier -59 with code 27762 provided on April 6, 2021.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 code 27762-59. Our reviewer says that the medical records support the billing of modifier -59 with code 27762 provided on April 6, 2021. Our physician reviewer found the operative report documents a diagnosis of "Trimalleolar fracture of the left ankle". The operative report describes an open treatment was performed on the lateral malleolus, as well as a closed treatment to the medial malleolus. In this case, modifier -59 is supported as a distinct procedural service, which was performed in a separate site, and injury.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 27762-59 have been met. Therefore, we decided that the Plan has to pay for the Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction (27762-59) provided on April 6, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tempus xT genetic testing panel provided on July 16, 2021.  You asked the Plan to pay for the Tempus xT panel. You say that this testing is medically necessary. The Plan denied your request. The Plan says some of these codes should be billed under one single panel code while others were billed with the wrong place of service code.  Medicare rules say that molecular diagnostic laboratory tests such as the test at issue are subject to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate and unique test identifier.  We looked at the file and Medicare rules. The Tempus xT panel has been reviewed through the MolDx process and was found to be noncovered as it did not meet Medicare medical necessity criteria. It does not appear that any of the other gene panels offered have been evaluated through this process. Based on this information, we decided that Medicare rules for coverage of the Tempus xT panel have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT genetic testing panel provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99203) billed to the enrollee for services provided on July 31, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee's claims history shows the enrollee was seen previously by this provider on December 13, 2019, which was processed and paid by the Plan on January 07, 2020. This provider has the same taxonomy code and tax identification number as the services in question. A Same Specialty Physician is defined as a Physician and/or Other Qualified Health Care Professional of the same group and same specialty reporting the same Federal Tax Identification number.  According to the Centers for Medicare Services (CMS), a "New Patient" is a patient who has not received any professional services from the physician or physician group practice (same physician specialty) within the previous 3 years. Per Medicare Claims Processing Manual Chap 12 sec 30.6.7 a new patient means a patient who has not received any professional services or other face to face service from the physician within the previous 3 years. This provider billed for services provided to this enrollee on December 13, 2019. Therefore, a claim for new patient services billed for July 31, 2021, does not meet the Medicare billing criteria.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, we find that code 99203 is not supported in the medical record. Specifically, this code is described as "office or other outpatient visit for the evaluation and management of a new patient." Based on the claim history, this enrollee is not a new patient to this provider as they were seen by the provider in December of 2019. Therefore, we decided that the Plan does not have to pay for physician services (99203) billed to the enrollee for services provided on July 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compressor and a segmental pneumatic appliance to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the pneumatic compressor and segmental pneumatic appliance from an OON provider. You say that it is imperative to begin the requested therapy immediately to avoid further complications. You say that the clinical documentation provided supports the need for requested items. The Plan denied your request. The Plan says the items in dispute can be provided within the network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor and a segmental pneumatic appliance to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided October 11, 2021.  You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. No clinical records were provided to support the services at issue. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spinal cord injection (62320) provided on October 11, 2021.  You asked the Plan to pay for the spinal cord injection (62320). You say that the procedure billed is for subarachnoid injection therefore the policy of interlaminar epidural injections is not applicable. You say that subarachnoid opioids are very effective for decreasing pain and the service should be paid. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of the service.   The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spinal cord injection (62320) have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the spinal cord injection (62320) provided on October 11, 2021.