Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110, 97140) provided August 24, 2020 to 
August 27, 2020. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services 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 97110, & 97140 are not supported in the medical record. Specifically, records were not 
provided for the billed dates of service. Based on this information, we decided that Medicare rules for coverage 
of the therapy services have not been met.

Therefore, we decided that the Plan does not have to pay for therapy services (97110, 97140) provided August 
24, 2020 to August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a colorectal cancer screening (81528) 
provided on April 5, 2021. 
 
You asked the Plan to waive the deductible for a colorectal screening. You say that most insurance companies 
pay for the full amount of this testing with no member cost sharing. You also say that you should not owe this 
cost sharing amount. The Plan denied your request. The Plan says the cost-share you are being charged is 
correct. 
 
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 there is a $5,600 deductible for covered medical services. 

The service at issue is subject to the Plan deductible of $5,600. The record shows that at the time this claim was 
processed, $1,239.82 of the $5,600 deductible had been met. The allowed amount of the claim is $508.87, 
resulting in a deductible obligation of $508.87. The EOC shows until you meet your yearly deductible, you pay 
up to 100% of the Medicare approved amount for a colorectal cancer screening. After you meet your 
deductible, you pay $0 for your covered services. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $5,600 deductible for covered medical services. This cost sharing is a contractual 
obligation that had not been met at the time a colorectal screening was received on April 5, 2021. Therefore, 
we decided that the Plan does not have to waive the deductible for a colorectal cancer screening (81528) 
provided on April 5, 2021.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that this member does not have complex nursing or medical needs requiring a resource intensive inpatient hospital setting.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar spinal surgery. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the requested sacroiliac joint injection is medically necessary. The Plan denied your request. The Plan says the requested sacroiliac joint injection is not medically necessary.
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 a sacroiliac joint injection. Our reviewer says that the requested sacroiliac joint injection is not medically necessary. Our physician reviewer found there is no evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. There are not at least 3 positive exam findings of SI joint dysfunction present on physical exam such as: Patrick's test (+), thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. The review has determined that the requested sacroiliac joint injections are not medically reasonable or 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 a sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your request. The Plan says that Retacrit is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary in this case. Retacrit is not FDA-approved for your diagnosis. The use of Retacrit is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that your condition does not meet Medicare criteria for Retacrit. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on November 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the enterolysis services coded 44005 and the exploratory laparotomy services coded 49000 provided on January 4, 2021.
You asked the Plan to pay for the enterolysis services and the exploratory laparotomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are bundled to another service billed on the same date.
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, we have confirmed that code the enterolysis services and the exploratory laparotomy services has a bundled relationship with code 44005 and 49000 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the enterolysis services coded 44005 and the exploratory laparotomy services coded 49000 provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and additional intraoral x-
ray provided on April 5, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and additional intraoral x-ray. You say that 
this was a routine check-up and you wouldn't have gone if you knew it would be denied. You say that you are 
qualified for two checkups every 6 months at no charge. The Plan denied your request. The Plan says that a 
comprehensive oral evaluation is only covered once every three years and only one intraoral x-ray is covered 
once every year.

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, a comprehensive oral evaluation is 
only covered once every three years and only one intraoral x-ray is covered per year. The Plan paid for a 
comprehensive oral evaluation provided on December 11, 2019 and one intraoral x-ray provided on April 5, 
2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation and additional intraoral x-ray provided on April 5, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa 20mg/2ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the Part B step therapy criteria has not been met. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Euflexxa is not approved as step criteria 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa 20mg/2ml syringe for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), preventive procedure (D1999), and complete series of intraoral x-rays (D0210) provided on March 12, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, preventive procedure, and complete series of intraoral x-rays. You say that you object to these charges because you were not informed of the fees over and above your dental coverage. The Plan denied your request. The Plan says the problem focused limited oral evaluation and preventive procedure are not covered. The Plan also says that the complete series of intraoral x-rays are covered once in a three year period.
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, problem focused limited oral evaluation (D0140) and unspecified preventive procedure (D1999) are not among those covered under this benefit. The contract says that complete series of intraoral x-rays (D0210) is limited to one set every three years. The record shows that you received a complete series of intraoral x-rays (D0210) on May 9, 2019 and your complete series of intraoral x-rays (D0210) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), preventive procedure (D1999), and complete series of intraoral x-rays (D0210) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the scaling and root planing (D4341 x 2) provided on April 6, 2021.
You asked the Plan to reimburse you for the dental services. You say that the dentist destroyed your gums. You say that you were in extreme pain. You say that your gums were bleeding for 4 days. You also say that you were given medication that you did not take because you thought you would be dead if you took them. The Plan denied your request. The Plan says scaling and root planing are not listed as covered services.
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 scaling and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the scaling and root planing (D4341 x 2) provided on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2020
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 4, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (36415, 82306, 84439, 84443, 84480) provided on April 7, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that your provider is not able to do lab work in office. You also say that you were given an authorization to have your blood drawn elsewhere and you believe the blood work is part of the specialized visit with your provider. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for outpatient diagnostic tests and therapeutic services and supplies including lab services at a hospital. You have been asked to pay a $45 copayment for laboratory services. The records show that the billing provider in this case was the hospital. The EOC confirms $45 is the required copayment for this service. 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 (36415, 82306, 84439, 84443, 84480) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 22,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes
will be considered part of the same panel.
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 pay for the services. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee had laboratory testing for an extensive number of pharmacogenetic
tests. The submitted documentation does not include clinical history to document a reasonable need for this
testing and does not indicate that the results of the testing will be used to make meaningful changes in clinical
management.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis; with contrast (74177) provided on February 10, 2021.
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 you must pay $325 per day for other Medicare-covered diagnostic radiology services that are not ultrasounds.
You have been asked to pay $325 for the Medicare-covered diagnostic radiology service provided. 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 computed tomography (CT) scan of the abdomen and pelvis; with contrast (74177) provided on February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, head or brain; without contrast material represented by common procedural terminology (CPT) code 70450 and billed for date of service March 18, 2021. You asked the Plan to pay for CPT code 70450. You say that the enrollee had multiple exams on the date of service in dispute. The Plan denied your request. The Plan says the CPT code in dispute was not billed with a modifier that represented the service was separate or distinct.
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, we have confirmed that code CPT code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography, head or brain; without contrast material represented by common procedural terminology (CPT) code 70450 and billed for date of service March 18, 2021.