Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).

You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and is non-covered.

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 ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is considered 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 the ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the breast ultrasound provided on January 15, 2021.

You asked the Plan to waive the copay for the ultrasound. You say that you disagree with the copay. The Plan denied your request. The Plan says the claim was processed 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 a $110 copay for Medicare-covered diagnostic radiology services. 

You have been asked to pay a $110 copay for the ultrasound. The ultrasound falls within the outpatient diagnostic tests 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 copay for the breast ultrasound provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the walker provided on February 20, 2021.

You asked the Plan to waive the cost share for the walker. You say that you were told the walker would be covered in full. The Plan denied your request. The Plan says per your plan, you pay a coinsurance.

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 20% coinsurance for durable medical equipment and related supplies. 

You have been asked to pay a 20% coinsurance for the walker. The walker falls within the durable medical equipment and related 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 cost share for the walker provided on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist visit provided on April 22, 2021.

You asked the Plan to waive the copay for the services provided. You say that copays are waived for surgical second opinions. The Plan denied your request. The Plan says the claim processed 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 a $45 copay for services in a specialist office. 

The file shows that you were seen by a cardiology specialist. You have been asked to pay a $45 copay for the services provided. The services fall within the physician services benefit category. Your contract shows that covered physician services include a second opinion by another network provider prior to surgery. However, your contract does not indicate the second opinion has a $0 copay.

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 copay for the specialist visit provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on March 14, 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 targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on March 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee does meet LTACH admission criteria and this is the best option for her care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate acute hospital care which has not been denied. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for low dose computed tomography (CT) scan of chest for lung cancer screening (71271) provided March 4, 2021.

You asked the Plan to waive the copayment for low dose CT scan of chest for lung cancer screening. You say that you do not owe a copayment for this service. The Plan denied your request. The Plan says that the copayment has processed correctly in this case.

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 enrollees must pay a $0 copayment for screening for lung cancer with low dose computed tomography. 

The Plan says you must pay a $55 copayment for low dose CT scan of chest for lung cancer screening. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for low dose CT scan of chest for lung cancer screening. Therefore, we decided that the Plan has to waive the copayment for low dose computed tomography (CT) scan of chest for lung cancer screening (71271) provided March 4, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental bone grafts and oral appliance (21127, 21085, 21212, 21210).

You asked the Plan to pre-approve dental bone grafts and oral appliance. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested services are dental in nature and not medical.

Medicare generally does not cover dental services. The Plan follows the same rule. 

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 dental bone grafts and oral appliance. Our reviewer says that the requested service does not meet the criteria for coverage. Our physician reviewer found in this case, the record indicates that the enrollee underwent stem cell transplant and has had oral graft versus host disease. The enrollee has facial tenderness secondary to cyst, abscesses and alveolitis. The record indicates that the enrollee is essentially edentulous. The record indicates that the requested procedure is to prepare for an oral appliance. The requested service is dental in nature. The requested service is not medically necessary and reasonable, as defined by Medicare rules, for the enrollee's specific clinical condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dental bone grafts and oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve dental bone grafts and oral appliance (21127, 21085, 21212, 21210).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 11, 2019.

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.

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 December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0031, 0032U, 81227, 81240, 81241, 81355, 81401) provided September 22, 2020.

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 coverage rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0031, 0032U, 81227, 81240, 81241, 81355, 81401) provided September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided March 8, 2021.

You asked the Plan to pay for the limited oral exam. You say that you had one tooth pulled in December 2020, and another pulled in March 2021. The Plan denied your request. The Plan says this service is a covered benefit, but you have exceeded the frequency limitation.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam once per plan year.

We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam provided by a different dentist was covered on March 8, 2021. Based on this information, we determined that the Plan's frequency limit for the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on March 8, 2021.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on February 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the enrollee was within an active plan of care approved by the prescribing provider. The Plan denied your request. The Plan says prior authorization was 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 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 physical therapy services provided on February 19, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 26, 2019.

You asked the Plan to pay for the services provided. You say that you did not have other insurance. The Plan denied your request. The Plan says the claim processed correctly.

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 contacted the provider for the primary explanation of benefits. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayments for the inpatient hospital stays from March 8 to March 13, and March 23 to March 25, 2021.

You asked the Plan to waive the deductible and copayments for the inpatient hospital stays. You say that the Plan should waive the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $1,000 deductible and $850 copayment per day for Inpatient Hospital Care. 

You have been asked to pay a total of $1784 in your deductible and in copayments ($84 remaining in your deductible and a $850 copayment per each visit) for the inpatient hospital stays. The inpatient hospital stays fall 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 deductible and copayments for the inpatient hospital stays from March 8 to March 13, and March 23 to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on March 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that you rendered medical services assuming the authorization was obtained. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 podiatry services provided on March 11, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on October 7, 2020.
You asked the Plan to pay for the services provided. You say that a screening diagnosis was not billed with the charge. The Plan denied your request. The Plan says the predictive screening testing is not a Medicare 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. We looked at the file and the rules. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing for screening purposes. The records provided do not indicate the testing was ordered due to signs or symptoms. Therefore, we decided that the Plan does not have to pay for the testing services provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transforaminal epidural injections provided on November 30, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 64479 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Because the primary procedure code is not covered, the add-on code, 64480, is also not covered. Therefore, we decided that the Plan does not have to pay for the transforaminal epidural injections provided on November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045) provided July 9, 2019.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.

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 radiology services was not filed until March 10, 2021. 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 radiology services (71045) provided July 9, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable venous access device (36591) performed on August 5, 2020.
You asked the Plan to waive the copayment for a collection of a blood specimen from an implantable venous access device. You say that you have never before had to pay a copayment for blood draws. The Plan denied your request. The Plan says that the correct copayment was applied.
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 enrollees must pay a $0 copayment for laboratory tests. The Plan says you must pay a $110.73 copayment for a collection of a blood specimen from an implantable venous access device. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for a collection of a blood specimen from an implantable venous access device. Therefore, we decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable venous access device (36591) performed on August 5, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.