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

We decided that the Plan does not have to pay for the AlloMap testing (81595).

You asked the Plan to pay for the AlloMap testing. You say that you would like reconsideration because this testing is a Medicare covered service. The Plan denied your request. The Plan says it is the provider's responsibility to bill the primary plan or any liability insurance before submitting the claim to the member's plan.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the AlloMap testing until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the AlloMap testing (81595).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological medical examination and evaluation (92014).

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration is covered. You must pay a $50 copayment for a medical eye exam.

You have been asked to pay a $50 copayment for the medical eye exam provided. The record indicates that this exam was diagnostic in nature with assessment and treatment planning for indicated conditions of the eyes. 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 ophthalmological medical examination and evaluation (92014).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (90792).

You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was filed untimely.

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 nursing facility care was not filed. 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 nursing facility care (90792).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a test for detecting genes associated with heart disease.

You asked the Plan to pay for the test for detecting genes associated with heart disease. You say that the test was medically necessary and the member met the requirements for the test. The Plan denied your request. The Plan says the provider is out-of-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 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 record shows the member was referred for the test by an out-of-network provider. 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 test for detecting genes associated with heart disease.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit and management of a new patient (99204), scanning computerized ophthalmic diagnostic imaging (92133), and the ophthalmic ultrasound (76514).

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that coverage includes outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. You pay nothing for these Medicare-covered services.

The Plan says you must pay a $10 copayment for the services provided. Based upon the Plan contract however, outpatient physician services provided for the diagnosis and treatment of diseases and injuries of the eye are covered and the enrollee pays nothing for these Medicare-covered services. Therefore, we decided that the Plan has to waive the copayment for the office visit and management of a new patient (99204), scanning computerized ophthalmic diagnostic imaging (92133), and the ophthalmic ultrasound (76514).

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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90792, 90836, 99213).

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.

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 mental health services (90792, 90836, 99213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental exam and cleaning (D0120, D1110).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for these services was exhausted at the time the services were performed.

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 dental benefit was exhausted at the time the services were rendered. The enrollee received dental services. These visits exhausted the $500 annual benefit. Therefore, we decided that the Plan does not have to pay for a dental exam and cleaning (D0120, D1110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (61510).

You asked the Plan to pay for the surgical services. You say that the surgical assistant's services were medically necessary. The Plan denied your request. The Plan says this type of provider is not eligible for payment.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (61510).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the service was provided by an out-of-network provider without prior authorization from 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for predictive genetic testing (81406).

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were screening tests and are 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, genetic testing, 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 predictive genetic testing (81406).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and the intraoral-periapical each additional radiographic image (D0230 x 5).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your dental policy.

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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and the intraoral-periapical each additional radiographic image (D0230 x 5).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMems device for the enrollee.

You asked the Plan to pre-approve the CardioMems device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 CardioMems device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMems is considered experimental or investigational in nature at this point in time. The efficacy of the CardioMems heart failure system is uncertain in the enrollee's clinical setting. Further clinical study is needed to determine the efficacy and safety of this device. 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 CardioMems device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMems device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services (45378).

You asked the Plan to waive the copayment for the surgical services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Ambulatory Surgical Services.

You have been asked to pay a $250 copayment for the surgical services. The surgical services fall within the Ambulatory Surgical 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 surgical services (45378).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device.

You asked the Plan to pre-approve the Coflex device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.

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 Coflex device. Our reviewer says that medical necessity has not been established. Our physician reviewer found the Coflex device remains experimental. More research is needed to show safety and efficacy. In addition, the medical records do not show there is spinal instability. Therefore, hardware is not needed. 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 Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee.

You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy is medically necessary. The Plan denied your request. The Plan says proton beam therapy is not covered by Medicare in this case.

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 proton beam therapy. Our reviewer says that proton beam therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more beneficial than other types of treatment. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Medicare coverage criteria are not 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve neurology services. You say that you have been unable to obtain the care you need, and you need care to resolve your condition from wherever you can receive it. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network neurologist.

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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your second hospital admission should be considered a continuation of your previous hospital admission. The Plan denied your request. The Plan says the cost-sharing described above applies each time you are admitted to the hospital.

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 $395 copayment per day for days 1 - 4, and $0 for additional Medicare-covered days for inpatient hospital care. 

You have been asked to pay a $1580 copayment (a $395 copayment per day for days 1 - 4) for the inpatient hospital stay. This stay falls within the inpatient hospital 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 the inpatient hospital stay.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.

You asked the Plan to pre-approve skilled nursing facility services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when four factors are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. Medicare coverage criteria are not 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the monitoring services.

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 that the claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The rules say that ICD-10 code E07.9 is to be reported for an intraoperative neurophysiology monitoring service (CPT/HCPCS codes 95940 or G0453) during a surgical procedure most accurately described by CPT codes 60220, 60240, 60254 or 60260.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that procedure codes G0453 and 95938 were not billed with the required diagnosis code E07.9; however, the Medicare rules clearly state that this diagnosis code is only required when billed for a procedure described by codes 60220, 60240, 60254 or 60260. The records show that the services at issue were rendered during a sternotomy not described by codes 60220, 60240, 60254 or 60260. The Plan has not provided any further documentation or Medicare rules to support that the services are not payable as billed. Therefore, we decided that the Plan has to pay for the monitoring services.

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.