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

We decided that the Plan does not have to waive the copayment for the transrectal ultrasound you had on February 10, 2021.
You asked the Plan to waive the copayment for the transrectal ultrasound. You say that you feel this service should be covered 100% because it is a preventive procedure. The Plan denied your request. The Plan says you were charged this copayment 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 $155 copayment for radiological diagnostic services. You have been asked to pay a $155 copayment for the transrectal ultrasound. The transrectal ultrasound falls within the radiological diagnostic 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 for the transrectal ultrasound you had on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 23, 2020.
You asked the Plan to pay for the laboratory services. You say that this is a medically necessary laboratory test for patients with advanced stage cancer who have decided to seek further treatment. You say that this provider is the sole provider of this test and the claim should be processed at the in-network benefit. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is not a network provider with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 laboratory services provided by an out-of-network provider on December 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) head or brain (70450).
You asked the Plan to pre-approve the CT scan. You say that you have a history of an accident from 2008. You've had 39 surgeries and already had an MRI, so you have to get a CT scan now and you want this done as soon as possible. The Plan denied your request. The Plan says a CT scan of the head is not medically necessary under the sub-acute head trauma guidelines.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in general, outside of the acute setting, CT of the head is not performed following head trauma (with some exceptions that are not present in this case). Rather if there is a need for imaging, an MRI is the preferred imaging modality and there was no contraindication to MRI noted. Nor was there sufficient information provided to establish that the requested imaging is otherwise reasonable and necessary for the evaluation of the enrollee's condition at this time. In as much the request would not meet Medicare criteria for coverage.
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) head or brain (70450).
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 you need more physical therapy than you can get at a lower level of care. The Plan denied your request. The Plan says you do not have complex needs.
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 patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the naturopath services rendered on December 11, 2020.
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the naturopath services rendered on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on September 16, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that the date of service (DOS) for either a clinical laboratory test or the technical component of physician pathology service must be the date the specimen was collected. We looked at the file and Medicare rules. The record shows that the specimen was collected on September 15, 2020, but this date was not billed as the date of service. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on September 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiology services you received on February 25, 2021.
You asked the Plan to waive the copayment. You say that you should only have a $45 copayment for the visit. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $110 copayment for Medicare-covered diagnostic radiology services. Review of the file shows that you were provided diagnostic radiology services on February 25, 2021. Per your contract with the Plan, there is a $110 copayment for diagnostic radiology services. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $39.31. Given that the allowed amount was less than the $110 copayment, you have been asked to pay $39.31 for these services. This means that you have been asked to pay the correct
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the radiology services you received on February 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient psychotherapeutic services provided on May 19 to
July 13, 2020, by a provider who has opted out of Medicare.
You asked the Plan to pay for outpatient psychotherapeutic services. You say that all representatives of the
Plan that you spoke to agreed that the charges at issue should be paid. The Plan denied your request. The Plan
says rules for payment have not been met because the provider at issue has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient
psychotherapeutic services provided on May 19 to July 13, 2020, by a provider who has opted out of Medicare.
Your complaint about receiving erroneous or incomplete information from representatives of the Plan 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 2, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.

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 testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on March 27, 2020.

You asked the Plan to pay for therapeutic exercises. You say that this should be covered as an in-network
service. The Plan denied your request. The Plan says this was not billed correctly.

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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this
service was performed in a home health setting. There is a more appropriate code for this service. Based on this
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met.
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on March
27, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the upper GI endoscopy and diagnostic colonoscopy. We decided that the Plan does not have to waive the copayment for the upper GI endoscopy.

You asked the Plan to waive the copayment for the upper GI endoscopy and diagnostic colonoscopy. You say that you had a routine colonoscopy, so you shouldn't have a copayment. The Plan says that you were charged this copayment correctly.

We decided that the Plan has to waive the copayment for the diagnostic colonoscopy.

Medicare rules require the Plan to clearly disclose cost sharing obligations in their Evidence of Coverage. In this case, the Plan has charged a $240 copayment for the upper GI endoscopy and an additional $50 copayment for the colonoscopy. The Plan says that the copayment charged for the colonoscopy was charged because diagnostic tests have a $50 copayment. We do not agree. First of all, a colonoscopy is not a diagnostic test--it is a surgical procedure. Second, this colonoscopy was done during the same visit as the upper GI endoscopy. According to your Evidence of Coverage, the copayment for outpatient surgery services is a PER VISIT copayment. In other words, if services are done in the same visit, only one copayment applies. That is why it is not appropriate for the Plan to charge a second copayment for services that occurred during the ambulatory surgery center visit on March 4, 2021.

We also decided that the Plan does not have to waive the copayment for the upper GI endoscopy.

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 $240 copayment per visit for services at an ambulatory surgery center. You did have a visit for surgical services at an ambulatory surgery center on March 4, 2021, so this copayment was charged correctly. Therefore, we decided that the Plan does not have to waive the copayment for the upper GI endoscopy.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil 20 mg tablet.

You asked the Plan to pre-approve Tadalafil. You say that this request is medically necessary. The Plan denied your request. The Plan says the Plan does not cover this drug under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil 20 mg tablet.

Benefits for Tadalafil may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power recliner with seat life mechanism.

You asked the Plan to pre-approve a recliner with seat life mechanism.. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a seat lift mechanism is covered for the indications established in the applicable LCD. 

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 recliner with seat life mechanism.. Our reviewer says that the requested recliner with seat lift mechanism is not medically reasonable and necessary. Our physician reviewer found that the documentation does not reveal objective evidence on imaging studies of severe arthritis of the hip or knee, or a severe neuromuscular disease.

The documentation does not reveal that the seat lift mechanism will affect improvement, or arrest or retard deterioration in the enrollee's condition. There is no objective exam evidence that the enrollee is completely incapable of standing up from a regular armchair or any chair in their home. The enrollee does have the ability to ambulate. The LCD coverage criteria for a seat lift mechanism have not been met.

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 recliner with seat life mechanism. have not been met. Therefore, we decided that the Plan does not have to pre-approve a power recliner with seat life mechanism.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical trays billed with Healthcare Common Procedure Coding System (HCPCS) code A4550 for date of service February 2, 2021.
You asked the Plan to pay for HCPCS code A4550. You say that there was an authorization on file for the services provided on the date of service in dispute. The Plan denied your request. The Plan says Medicare does not recognize the code which remains in dispute. The Plan says that a corrected claim can be submitted to the claims address with a code recognized by Medicare for claim reconsideration.
The Plan must follow Medicare rules. Medicare rules say that HCPCS code A4550 is no longer separately payable and that these supplies have been incorporated into the practice expense RVU.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HCPCS code A4550 have not been met. Therefore, we decided that the Plan does not have to pay for surgical trays billed with Healthcare Common Procedure Coding System (HCPCS) code A4550 for date of service February 2, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer risk screening testing provided on February
3, 2021.
You asked the Plan to pay for genetic testing. You say that this testing can help predict the likelihood that
prostate cancer will be found by a biopsy. The Plan denied your request. The Plan says the denial of payment
for this testing is correct, because prostate predictive screening testing is not a Medicare benefit.
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, genetic testing, was requested for screening purposes. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for prostate cancer
risk screening testing provided on February 3, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic panel testing provided on October 10, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. The records do not show that the enrollee exhibited signs or symptoms that warranted the provided testing. The testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic panel testing provided on October 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH is not
medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report (93000) provided January 20, 2021.
You asked the Plan to pay for the diagnostic service. You say that you received a bill for $10 for an EKG and feel the copay should be waived because it was a part of the annual physical. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage. ECG services are not considered part of an annual physical exam.
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 $10 per day for outpatient diagnostic tests. You have been asked to pay $10 for the diagnostic service. 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 pay for the routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report (93000) provided January 20, 2021.