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

We decided that the Plan does not have to pay for the drug testing services provided on May 14, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code cannot be verified. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim submitted shows a place of service as an independent lab. The records provided show that the enrollee's specimen was obtained at the physician's office. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computed tomography (CT) scan of the lumbar spine (72131) provided January 21, 2021.You asked the Plan to waive the copayment forthe CT scan of the lumbar spine. You say that you disagree with this copayment because you previously had other CT scans.The Plan denied your request. The Plan says the copayment has processed 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 $225 copayment for advanced imaging services. You have been asked to pay a $225 copayment for the CT scan of the lumbar spine. This service falls within the advanced imaging services 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 forthe computed tomography (CT) scan of the lumbar spine (72131) provided January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (Current Procedural Terminology (CPT) code(s): 81407 and 81408) provided to the enrollee on December 15, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The member had cardiovascular risk assessment testing on December 15, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (Current Procedural Terminology (CPT) code(s): 81407 and 81408) provided to the enrollee on December 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3D rendering for a magnetic resonance imaging (MRI).
You asked the Plan to pre-approve the 3D rendering. The Plan denied your request. The Plan says there is no evidence of a biliary obstruction.
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 3D rendering. Our physician reviewer found that based on the clinical presentation and initial workup being somewhat inconclusive, the MRI of the abdomen is warranted and was approved by the Plan. The 3D rendering is not justified as it would not significantly change the image results or overall outcome in this specific situation. Therefore, the 3D rendering will be considered not medically 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 3D rendering have not been met. Therefore, we decided that the Plan does not have to pre-approve a 3D rendering for a magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out of network (OON) provider on
November 19, 2020.

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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out of network (OON) provider on November 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe interpretation of the abdominal x-ray provided on February 24, 2021 reported with place of service (POS) code 22.You asked the Planto pay forthe x-ray interpretation. You say that the correct POS code was used.The Plandenied your request. The Plansaysthe enrollee was an inpatient at the time of this service.The Plan must follow Medicare rules. Medicare rules say that the POS code for a registered inpatient should be the inpatient POS code 21. In this case, the enrollee was an inpatient at the inpatient rehabilitation facility (IRF) from February 29, 2021, through March 1, 2021. As such, the appropriate POS code for this claim would be 21. Therefore, we decided that the Plandoes not haveto pay forthe interpretation of the abdominal x-ray provided on February 24, 2021 reported with place of service (POS) code 22.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 31, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you were not aware of the benefit and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for specialist services. You have been asked to pay a $10 copayment for a specialist visit. A specialist 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 a specialist visit provided on March 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on December 7, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that if the clinic had the CT scan machine you would not have had to go to the emergency room. The Plan denied your request. The Plan says the correct copayment has been 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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for an emergency room visit. Since an emergency room visit took place, the correct copayment has been applied.
An emergency room visit falls within the emergency care 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 emergency room visit provided by a participating provider on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Other Diagnostic Services-Peripheral Vascular Lab provided February 3, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that Medicare should cover the entire cost and copay of the ultrasound ordered by your PCP. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage
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 $50 copayment for basic radiological services in a freestanding radiological facility.
You have been asked to pay $50 copayment for the diagnostic services. the diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 Other Diagnostic Services-Peripheral Vascular Lab provided February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for or pay an additional amount forthe extraction, erupted tooth or exposed root (D7140), the immediate denture -maxillary (D5130), and the drugs or medicaments dispensed in the office for home use (D9630) received October 26, 2020.You asked the Plan to pay for or pay an additional amount forthe dental services. You say that the agent was not truthful about what would be covered under your benefit.The Plan denied your request. The Plan says the claim paid according to your benefit.Medicare generally does not cover dental services. However, the Plan offersa 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 in excess of those covered under this benefit.The Plan does not offer coverage for drugs or medicaments dispensed in the office for home use (D9630). The Plan limits coverage of dental extractions to two procedures per calendar year. The Plan has submitted evidence that the Plan covered two of the extractions received on this date of service.After the first two extractions your benefit is exhausted, and you are responsible for paying for the remaining extractions. The Plan covers dentures, with certain limitations. Coverage of dentures requires a 70% coinsurance. The Plan's allowed amount for the maxillary denture was $1,174.00. Your cost share of a 70% coinsurance is $821.80. You have been asked to pay the correct amount for the requested services. Therefore, we decided that the Plan doesnot have to pay for or pay an additional amount forthe extraction, erupted tooth or exposed root (D7140), the immediate denture -maxillary (D5130), and the drugs or medicaments dispensed in the office for home use (D9630) received October 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the shoulder (73030) provided on March 22, 2021.
You asked the Plan to waive the copayment for an x-ray of the shoulder. You say that you should not be charged an additional copayment for the second x-ray. You also say that you should not owe any cost-share. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $25 copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $25 copayment for an x-ray of the shoulder. The records show that you were only charged for one x-ray. The EOC confirms $25 is the required copayment for this service. An x-ray of the shoulder falls within the outpatient diagnostic tests and therapeutic services and supplies 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 x-ray of the shoulder (73030) provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test 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 laboratory services rendered on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit (99214) electrocardiogram, routine ECG with at least 12 leads (93000) single-level lower extremity physiologic study (93922) provided on October 16, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. You say that you ask as a one-time courtesy to please waive the authorization policy and reprocess this claim for payment as soon as possible.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 priorauthorization 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 forthe outpatient office visit (99214) electrocardiogram, routine ECG with at least 12 leads (93000) single-level lower extremity physiologic study (93922) provided on October 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services (99100) provided on August 10, 2020.You asked the Plan to pay foranesthesia services. You say that the enrollee was not able to choose their anesthesia provider.The Plan denied your request. The Plan says this is not separately payable.The Plan must follow Medicare rules. Medicare rules say that that status code B indicates that payment for covered services isalways bundledinto payment for other services not specified.  We looked at the file and Medicare rules.The code at issue, 99100, has a status code of B.Based on this  information, we decided that Medicare rules for coverage of anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay foranesthesia services (99100) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management service before and/or after direct patient care, first hour (99358) prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (99359) telemedicine, 21-30 minutes (99443) provided on February 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the evaluation and management services. You say that your doctor provided medically necessary services to the enrollee in good faith, and in return you are expecting reimbursement. 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 prolonged evaluation and management service before and/or after direct patient care, first hour (99358) prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (99359) telemedicine, 21-30 minutes (99443) provided on February 9, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist (99214) provided on January 14, 2021, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that the visits with this provider are needed for your quality of life and the delay of the conditions detected. The Plan denied your request. The Plan says there are in-network providers available for these services.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a specialist (99214) provided on January 14, 2021, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOzurdex and its subsequent administration provided February 18, 2021.You asked the Plan to pre-approveOzurdex. You say that you would like this claim reprocessed and approved for payment.The Plandenied your request. The Plan says the clinical value and effectiveness of Ozurdex in the setting of retinal edema without following documented branch or central retinal vein occlusion have not been demonstrated in the peer-reviewed literature.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 Ozurdex. Our reviewer says that the requested drug was not medically reasonable and necessary. Our physician reviewer found the Food and Drug Administration has stated that Ozurdex is indicated in adults for the treatment of macular edema following branch retinal vein occlusion or central retinal vein occlusion, diabetic macular edema in pseudophakic or phakic patients who are planning to have cataract surgery, and for thetreatment of non-infectious uveitis affecting the posterior segment of the eye. In this case, the enrollee has retinal edema. The medical record does not indicate that the enrollee has central or branch retinal vein occlusion. The elements of the coveragecriteria are not satisfied.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ozurdex have not been met.Therefore, we decided that the Plan does not have to pre-approveOzurdex and its subsequent administration provided February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea breast magnetic resonance imaging (MRI) scan.You asked the Plan to pre-approvebreast MRI. You say that regular mammography gives you severe pain in the chest and shoulders.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not indicate what other tests have been performed for you, why other tests cannot be done first, and how this MRI would change how your physician treats you.The Plan follows Medicare rules. Medicare rules state that breast MRI is only to be used in specific circumstances.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 breast MRI. Our reviewer says that you do not meet the Medicare criteria for the requested breast MRI. Our physician reviewer found you prefer this MRI because of your history of broken shoulder which causes pain during mammography sessions, but your physician still preferred a mammogram based on the medical records. Shoulder discomfort during mammography is not an indication for an MRI.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvea breast magnetic resonance imaging (MRI) scan.