Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer provided by an out-of-network provider on February 17, 2021.

You asked the Plan to pay for the nebulizer. You say that authorization is not required for purchase items that are reimbursed at or below $500. The Plan denied your request. The Plan says prior authorization was required but not obtained. The Plan also says that durable medical equipment under $500 does not require authorization if the provider billed with Place of service 11.

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 nebulizer provided by an out-of-network provider on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on March 18, 2021.

You asked the Plan to waive the deductible for the laboratory services. You say that the PSA screening is
covered by insurance at 100%. You say that screenings should be diagnosed age appropriately so senior
citizens are not charged inappropriately. The Plan denied your request. The Plan says the deductible applied
correctly.

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 your deductible is $250. This is the amount you have to pay out-of-pocket for
in-network and/or out-of-network services before we will pay our share for your covered medical services.
Until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $250 deductible applies to outpatient diagnostic tests. A PSA test is not
considered a screening with a history of hyperplasia of the prostate.

This cost sharing is a contractual obligation that had not been met at the time the laboratory services were
received on March 18, 2021. Therefore, we decided that the Plan does not have to waive the deductible for
laboratory services provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 4, 2021.

You asked the Plan to pay for the laboratory services. You say that the enrollee should be eligible for the Genesight Psychotropic (81479). The Plan denied your request. The Plan says there is not a pregnancy, two cases were performed on the same date of service and there is not a signed order.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. There was no specific clinical rationale for the requested GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 4, 2021. The medical records provided did not meet the requirements listed in the LCD for Medicare coverage. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation provided by an out-of-network
provider on January 29, 2021.

You asked the Plan to pay for the telephone evaluation. You say that you had been seeing this doctor through
your previous insurance and thought you would be covered under your new plan. The Plan denied your request.
The Plan says there is no prior authorization on file and in-network providers were available.

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 telephone evaluation provided by an out-of-network
provider on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tocilizumab injection provided on October 2, 2020.

You asked the Plan to pay for the Tocilizumab injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support the units 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.

In this case, the CPT Code Manual definition of code J3262 is injection, tocilizumab, 1 mg. 

We find that CPT code J3262 is not supported in the medical record. Specifically, 80 units of this service were billed. The submitted medical records do not support 80 units. The documentation indicates that the provider administered 450 mg of Actemra and discarded 30 mg of Actemra. The waste is required to be billed on a separate claim line with modifier JW; therefore, the code billed and validity and accuracy of the units billed cannot be verified. Based on this information, we decided that Medicare rules for coverage of the Tocilizumab injection have not been met. Therefore, we decided that the Plan does not have to pay for the Tocilizumab injection provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on November 12, 2020, by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you provided care for the member during an emergency room visit and thought a follow up visit did not require an authorization. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99214) provided on November 12, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast reconstruction services coded 19366 provided on December 17, 2020.

You asked the Plan to pay for the breast reconstruction 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 not supported by the documentation.

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 19366 is repair and/or reconstruction procedures on the breast.

We find that CPT code 19366 is not supported in the medical record. Specifically, the operative report did not include documentation of a breast reconstruction with other technique; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the breast reconstruction services have not been met. Therefore, we decided that the Plan does not have to pay for the breast reconstruction services coded 19366 provided on December 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided December 31, 2020, to February 5, 2021.

You asked the Plan to waive the copayment for SNF care. You say that you were never told there would be cost shares for this service and you did not sign any papers. 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 $0 copayment, for days 1-20, and a $95 copayment, for days 21-65, for skilled nursing facility (SNF) care. Your contract with the Plan also says that a benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.

You have been asked to pay a $95 copayment per day, for SNF care. The records show that you were previously admitted to a SNF on November 30, 2020, to December 19, 2020, for a total of nineteen (19) days. The records also show that you were admitted to a different SNF on December 31, 2020, to February 5, 2021, for a total of thirty-six (36) days. You are covered for SNF care with a $0 copayment for days 1-20. You were not charged a copayment for your first twenty (20) days. The $95 copayment is assessed from day 21-65 assessing you a total cost share of $3,325 ($95 x 35 days = $3,325). 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 skilled nursing facility (SNF) care provided December 31, 2020, to February 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on December 10, 2020.

You asked the Plan to pay for the hospital services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable 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 the hospital services are not supported in the medical record. Specifically, these services were
billed as type of bill (TOB) 78x, which is not a Medicare recognized type of bill for an outpatient hospital.
Outpatient hospital claims would be billed on type of bill 13x or 14x. This means the incorrect type of bill was
billed. Based on this information, we decided that Medicare rules for coverage of the hospital services have not
been met. Therefore, we decided that the Plan does not have to pay for the hospital services provided on
December 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound exam (76770) and the computed tomography (CT) scan of the abdomen and pelvis (74178) provided on December 1, 2020 and December 23, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for advanced imaging services provided at an outpatient hospital and a $95 copayment for basic radiological services provided at an outpatient hospital.

You have been asked to pay $370 ($275 copay + $95 copay) for the advanced imaging and basic radiological service provided at an outpatient hospital. 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 copayments for the ultrasound exam (76770) and the computed tomography (CT) scan of the abdomen and pelvis (74178) provided on December 1, 2020 and December 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on July 9, 2020.

You asked the Plan to pay for the therapeutic exercises. The Plan denied your request. The Plan says the
documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents
to justify payment of the claim.

Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not
been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on July
9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 86141, 83090, 82607, 84481, 84550, 85025, 83615, 84144, 84270, 84403, 80053, 82533, 82627, 82670, and 82746 provided on July 13, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 the laboratory services are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 86141, 83090, 82607, 84481, 84550, 85025, 83615, 84144, 84270, 84403, 80053, 82533, 82627, 82670, and 82746 provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge management provided by an out-of-network provider on January 26, 2021.

You asked the Plan to pay for the nursing facility discharge management. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided necessary services and the claim should be processed for payment at the maximum allowed amount. The Plan denied your request. The Plan says prior authorization was required but not 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 nursing facility discharge management provided by an out-of-network provider on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on March 5, 2021.

You asked the Plan to pay for the office visit. You say that a health care plan should provide coverage for an initial medical screening required by the emergency medica treatment and active labor act. You say that the treatment provided was medically necessary and the claim should be processed in-network. The Plan denied your request. The Plan says prior authorization was required but not 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 office visit provided by an out-of-network provider on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81401, 81403, 81404, 81405,
81406, 81185 and 81479 provided on November 24, 2020.

You asked the Plan to pay for the laboratory 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 not supported by the documentation.

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 81401, 81403, 81404, 81405, 81406, 81185 and 81479 are not supported in the
medical record. Specifically, the documentation does not contain evidence of an established relationship with
the ordering physician. Based on this information, we decided that Medicare rules for coverage of the
laboratory services have not been met.

Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81401, 81403,
81404, 81405, 81406, 81185 and 81479 provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia provided on February 17, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the surgical extraction and deep sedation/general anesthesia. You say that you paid the bill in full, expecting to be reimbursed because no one advised you that the provider had opted out of Medicare. The Plan denied your request. The Plan says the treating provider has opted out of Medicare. The Plan also says that services provided by an opt out provider are not covered.

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 covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the surgical extraction, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia provided on February 17, 2021 by a Medicare opt out provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
November 26, 2020, through November 30, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was found on the floor with no injuries. She had no COVID-19 signs or symptoms. Regarding rehabilitation services, the enrollee did not receive nor require any skilled services. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from November 26, 2020, through
November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 26, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. 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.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36523 to support their denial. However, LCD L36139, L36129 and L36523 are not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36139, L36129 and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on January 26, 2021.