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

We decided that the Plan does not have to pay for the laboratory services provided on February 20, 2020 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 the laboratory services provided on February 20, 2020 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on June 30, 2020.

You asked the Plan to pay for the home visit. You say that authorization is not required when an out-of-network provider sees a patient in a facility. You say that the claim should be reprocessed and paid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 the home visit provided by an out-of-network provider on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on October 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the office visit and related services provided on October 6, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479, 81225, 81226, 81227, 81355, 81401) provided on April 23, 2020.
You asked the Plan to pay for genetic testing. You say that this is supported in the records. The Plan denied your request. The Plan says these codes cannot be paid 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 find that CPT codes 81479, 81225, 81226, 81227, 81355 and 81401 are not supported in the medical record. Specifically, the submitted records contain documentation of drug testing rather than genetic testing. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479, 81225, 81226, 81227, 81355, 81401) provided on April 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says this device is not covered by
Medicare.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits you had from January 1, 2021, to February 4, 2021.
You asked the Plan to waive the copayment. You say that you cannot afford to pay for the services. 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 $25 copayment for each specialist visit. Review of the file shows that you had office visits from January 1, 2021, to February 4, 2021. You have been asked to pay a $25 copayment for each visit. The visits fall within the physician 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 office visits you had from January 1, 2021, to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided February 2, 2021.
You asked the Plan to pay for the chiropractic treatment. You say that this should have been an in-service charge. The bill jumped from $8.29 to $40.79. The Plan denied your request. The Plan says this claim has been processed with the correct copayment applied per the plan's 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 $65 copayment for out of network Medicare covered chiropractic services in a specialist's office. You have been asked to pay $40.79 copayment for the chiropractic treatment. Since this amount is less than the copay amount, you are responsible for the lesser amount. the chiropractic treatment falls within the Chiropractic 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 pay for the chiropractic manipulative treatment (98941) provided February 2, 2021.
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 (99335) and removal of noncancer thickened skin growth (11056)
provided on December 9, 2020, by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit for the evaluation and management of an
established patient and removal of noncancer thickened skin growth. You say that the care provided was
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says prior
authorization was not obtained for these services rendered by an OON provider.

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 the domiciliary or rest home visit for the
evaluation and management of an established patient (99335) and removal of noncancer thickened skin growth
(11056) provided on December 9, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230),
and a panoramic radiographic image (D0330) provided on January 28, 2021.
You asked the Plan to pay for intraoral periapical radiographic images, and a panoramic radiographic image.
You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the
services at issue are not covered benefits.
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 intraoral periapical radiographic images (D0220, D0230), and a panoramic radiographic image (D0330) provided on January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient physician services provided on July 24, 2019.
You asked the Plan to pay for the outpatient physician's services. The Plan denied your request. The Plan says the claim was received past the 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the outpatient physician's services was not filed until December 31, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for outpatient physician services provided on
July 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography (77065) provided October 15, 2020.
You asked the Plan to pay for the diagnostic mammography. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says they did not have enough information to approve coverage.
The Plan follows Medicare rules. The 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. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the diagnostic mammography (77065) provided October 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tremfya injection 100mg/ml for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this medication was denied due to a benefit exclusion.
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 Tremfya injection 100mg/ml for the enrollee.
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 the clinical information provided supports the need
for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have
not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a stroke and was transferred to skilled nursing on May 11, 2021. She was discharged home on
June 7, 2021, with home health services. There is ongoing weakness. The enrollee's medical conditions are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. The enrollee does require physical and occupational therapy but there is no documented need
for an intensive rehabilitation program. Medically necessary services can be provided in a different level of
care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an IRF.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing radiographic images (D0274) provided on February 8, 2021.
You asked the Plan to pay for bitewing radiographic images. You say that you did not know this service was not covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 bitewing radiographic images (D0274) provided on February 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (77012) provided on May 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service has already been paid.
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 a second unit of CPT code 77012 is not supported in the medical record. Specifically, the records show that only one CT scan guided needle biopsy was provided on May 15, 2020. This code has already been paid by the Plan. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (77012) provided on May 15, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-emergent ambulance service (A0428) and ground mileage (A0425) provided on February 22, 2021.
You asked the Plan to pay for the non-emergent ambulance service and ground mileage. The Plan denied your request. The Plan says that the claim does not meet the requirements for coverage.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance service and ground mileage. Our reviewer says that these services meet coverage criteria. Our physician reviewer found it is medically appropriate to consider ambulance services for the transportation of this enrollee given that she is only alert and oriented to person and place, and has symptoms of catatonia. Our reviewer also found that the enrollee's mental condition would need to be closely watched while in transport, and this could not be done with a non-medical van. 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 non-emergent ambulance service and ground mileage have not been met. Therefore, we decided that the Plan has to pay for the non-emergent ambulance service (A0428) and ground mileage (A0425) provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyewear provided on
February 23, 2021.
You asked the Plan to pay an additional amount for the eyewear. The Plan denied your request. The Plan says the supplemental eyewear allowance was applied to the retail value of the eyewear.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan has paid the correct amount for the eyewear based on the Plan's supplemental eyewear allowance benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received January 26, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not have any oral care for over a year and a half. The Plan denied your request. The Plan says the requested service has a frequency limit of one procedure every three years.
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 the comprehensive oral evaluation once every three years. We looked at the file, and Medicare rules. The Plan has submitted evidence that the Plan paid for a comprehensive oral evaluation on August 23, 2019. This benefit was exhausted when you next received it on January 26, 2021. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not been met.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Afirma Genomic Sequencing Classifier and Afirma Xpression Atlas (81210 81275 and 81311) provided on October 31, 2020.

You asked the Plan to pay for the Afirma panels. You say that you would like reconsideration because determining the optimal surgery and ensuring that the member does not require an additional surgery is in the best interest of the member. The Plan denied your request. The Plan says service providers should use CPT code 81479 at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test.

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 81210 81275 and 81311 is not supported in the record. Specifically, the record shows the the Afirma Xpresion Atlas testing was ordered and provided. This panel includes the BRAF gene. The Xpression Atlas testing is not a covered benefit. Additionally, the Genomic Sequencing Classifier testing has not been billed correctly or with an appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the Afirma panels have not been met. Therefore, we decided that the Plan does not have to pay for the Afirma Genomic Sequencing Classifier and Afirma Xpression Atlas (81210 81275 and 81311) provided on October 31, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the ankle foot orthosis provided on November 24, 2020.
You asked the Plan to pay for the ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf (L1906RT). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says that the information in the enrollee's medical record does not adequately support the medical necessity for the orthosis
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 ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf (L1906). Our reviewer says that the orthosis is medically necessary. Our physician reviewer found the documentation supports that the enrollee requires stabilization for medical reasons and has the potential to benefit functionally. 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 ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf (L1906) have been met. Therefore, we decided that the Plan has to pay for the ankle foot orthosis provided on November 24, 2020.
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.