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

We decided that the Plan does not have to pay for the laboratory services rendered on February 15, 2021.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 2021.
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 procedure code 87631 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 87631 is infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We find that CPT code 87631 is not supported in the medical record. Specifically, the records show that more than five targets were tested. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for surgery you had on March 25, 2021.
You asked the Plan to reduce the cost sharing for the surgery. You say that you believed you were admitted as an inpatient, so you should only have to pay the inpatient copayment. You stated that prior to the surgery, you called the Plan and were advised that if you were admitted, the inpatient copayment would apply. You stated that you were never told to contact the hospital to see if you would be treated as an inpatient or an outpatient. The Plan denied your request. The Plan says you were not admitted as an inpatient to the hospital, so the outpatient cost sharing applied 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 20% coinsurance for outpatient surgery. You have been asked to pay 20% coinsurance for the surgery. Your Evidence of Coverage explicitly advises you that if you are having surgery in a hospital, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you may still be considered an outpatient. 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 reduce the cost sharing for surgery you had on March 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on December 11, 2020, to December 30, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and paid. You say that the doctor made the determination that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physical therapy provided on December 11, 2020, to December 30, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve genetic testing for ataxia (81177, 81179, 81184, 81178).
You asked the Plan to pre-approve the genetic testing. You say that the testing is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 genetic testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the member's Magnetic Resonance Imaging (MRI) exams are noted to show findings including volume loss of the pons and cerebellum. He is also noted to have had abnormalities potentially suggestive of an ataxia on exam. In this setting the performance of a limited genetic testing panel for genes that are readily associated with such a presentation would be consistent with standards of care and would be medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has to pre-approve genetic testing for ataxia (81177, 81179, 81184, 81178).
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 pre-approve mental health therapy to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve mental health therapy. You say that there are not any therapists available that specialize in Exposure Response Prevention Therapy (ERPT) and you need frequent visits. 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 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 requested provider is a licensed professional counselor (LPC) and such services by an LPC are not covered by Medicare. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. 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 mental health therapy 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you require therapy after your surgery. The Plan denied your request. The Plan says the care required by the enrollee could be provided at a lower level of care.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The reviewer found that your medical problems are stable and there are no complex nursing or rehabilitation needs. The reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The reviewer found that there is no documented need for a intensive, multi-disciplinary rehabilitation program. The reviewer also found that there is not a reasonable expectation that you 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. Specifically, the file does not show that there is a documented need for a intensive, multi-disciplinary rehabilitation program. 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 anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) rendered by the out-of-network (OON) provider on April 22, 2021.
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 anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) rendered by the out-of-network (OON) provider on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on April 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that it is the nursing facility's responsibility to obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician or the nursing facility.
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 skilled nursing services provided on April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 4, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you have financial assistance with the provider were services are 100% covered and cannot afford 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 lab services. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on February 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on December 2, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable.

The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 70450 is part of an edit pair with procedure code 70460. Procedure code 70460 is a column one code, and procedure code 70450 is a column two code. Procedure code 70460 has been billed on this date of service, which means that procedure code 70450 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the implanted pump refill provided on April 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the implanted pump refill. You say that you were told authorization was not required. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 implanted pump refill provided on April 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Invacare Rigid Standard Wheelchair.

You asked the Plan to pre-approve the Invacare Rigid Standard Wheelchair (Brand Specific). You say that you need this wheelchair to be able to go everywhere, drive your van and use your arms. The Plan denied your request. The Plan says brand specific equipment is not covered by the Plan or by Medicare and equipment for use outside the home also is not covered the Plan or by Medicare.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The brand specific wheelchair requested has features not required for use in the home. Although this item may be beneficial for you to use, neither Medicare nor the Plan covers this type of equipment. Therefore, we decided that the Plan does not have to pre-approve an Invacare Rigid Standard Wheelchair (Brand Specific).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there is no clinical
advantage of IRF care over acute hospital care.

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 physician reviewer found
that you were admitted to the acute care hospital for sepsis and encephalopathy. The complexity of your
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis and fluoride varnish application provided on April 15, 2021.
You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis and fluoride varnish application. You say that your dentist provides the best care and meets your expectations for dental maintenance. You say that you feel most comfortable using your dentist and they should be covered in-network. The Plan denied your request. The Plan says this dentist is not a network provider with the Plan and in-network providers were available.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis and fluoride varnish application provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953 x 2) provided on April 23, 2021.
You asked the Plan to pay for the dental service. You say that you received a bill for $2,484. You also say that no one told you that the procedure was not covered. The Plan denied your request. The Plan says bone replacement graft for ridge preservation is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 the bone replacement graft for ridge preservation (D7953 x 2) provided on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 26, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on May 22, 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.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The service at issue in this appeal was not provided in an emergency or urgent care situation. This service was not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam and core buildup provided on April 2, 2021.
You asked the Plan to pay for the amalgam and core buildup. You say that there were no appointments available for months at a network dentist. You say that this was a temporary fix to relieve pain and payment should be provided since it was an emergency. The Plan denied your request. The Plan says there is no coverage for services rendered by an out-of-network provider.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the amalgam and core buildup provided on April 2, 2021.