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

We decided that the Plan does not have to pay for unclassified drugs (J3490) provided on June 19, 2020.
You asked the Plan to pay for the unclassified drugs. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of 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 J3490 is unclassified drugs. We asked our coder 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 unclassified drugs. Our reviewer says that CPT code J3490 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to support the 9 units of J3490 that were billed, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unclassified drugs have not been met. Therefore, we decided that the Plan does not have to pay for unclassified drugs (J3490) provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for manual manipulation of the spine and non-covered chiropractic services (CPT code(s) 97112, 99202, 72050, 98941) provided from August 18, 2020, through September 3, 2020, by an out-of-network provider.
You asked the Plan to waive the cost-share for the chiropractic services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits and the Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). For dates of service August 18, 2020 to September 3, 2020, and September 19, 2020 was partially overturned because updated diagnosis information was received from the provider. The claim has been processed with out-of-network chiropractic benefits per pages 65-66 of the EOC. Your responsibility is $65. The rationale for upholding the original determination for codes 97012, 97112, 99202, 99212, 72050, 72100, 72080, 77071, and 72020 is as follows: "This policy only covers manual manipulation of the spine to correct subluxation; other services performed by a chiropractor are not covered." Code 99070 represents the two Durable Medical Equipment (DME) items added and paid to the claim. Therefore, we decided that the Plan does not have to waive the cost-share for manual manipulation of the spine and non-covered chiropractic services (CPT code(s) 97112, 99202, 72050, 98941) provided from August 18, 2020, through September 3, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Next Generation Sequencing (NGS) TrueSight Cancer screening (CPT code(s) 81201, 81235, 81272, 81321, 81404, 81405, 81405, 81407, 81408 and 81479) provided on September 24, 2020.
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. These services are not authorized because molecular genetic hereditary predictive screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. Therefore, we decided that the Plan does not have to pay for Next Generation Sequencing (NGS) TrueSight Cancer screening (CPT code(s) 81201, 81235, 81272, 81321, 81404, 81405, 81405, 81407, 81408 and 81479) provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code(s) 81173, 81120 and 81121) provided on August 12, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory testing. You say that the services were medically necessary. The Plan denied your request. The Plan says charges for, or in connection with services or supplies that are considered to be experimental or investigational are excluded from coverage under your plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory testing (CPT code(s) 81173, 81120 and 81121) provided on August 12, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Evenity (J3111).
You asked the Plan to provide Evenity (J3111). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this treatment is for postmenopausal osteoporosis, not for men.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 provide Evenity (J3111). Our reviewer says that the drug is not medically necessary. Our physician reviewer found criteria for Evenity not met. The male patient has not tried and failed other standard meds for osteoporosis. Furthermore, the FDA has not cleared Evenity for use in male patients. It is not needed in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity (J3111) have not been met. Therefore, we decided that the Plan does not have to provide Evenity (J3111).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 10, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 10, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are provided by an in-network provider. 

We looked at the file and the Plan's rules. The requested hearing aid services were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amiodarone.
You asked the Plan to pre-approve Amiodarone. You say that blockages and clots can lead to a stroke. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amiodarone.
Benefits for Amiodarone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (CPT code L1971 RT-KX) provided to the enrollee on September 4, 2020.
You asked the Plan to pay for the orthosis. You say that the services were necessary. The Plan denied your request. The Plan says the services are not supported by the records. The Plan states a review of the enrollee's claim history was conducted and showed that there was not a claim for the ordering physician. The Plan states that you did not present any medical records showing that the prescribing physician ever saw the enrollee.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. The providers are not listed in this enrollee's history of claims. There were no services found for the enrollee billed on the service date presented in the documents. The claim should be denied due to it appears this enrollee did not receive video or telephonic visit by the ordering physician in order to warrant the code(s) billed. Furthermore, there are no claims on file with the ordering physician listed in the enrollee's claims history 2019-present. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (CPT code L1971 RT-KX) provided to the enrollee on September 4, 2020.
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 need rehabilitation facility services. The Plan denied your request. The Plan says inpatient rehabilitation services are not medically necessary.
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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (CPT code A0427) provided to the enrollee on July 7, 2020.
You asked the Plan to pay for the ambulance services. You say that this was a 911 emergency call, the enrollee was assessed, vitals were taken at the scene and the enrollee was triaged to BLS transport to the emergency department. The Plan denied your request. The Plan says the enrollee was not actually transported by ambulance; this expense is not covered by the enrollee's benefit plan. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. Medicare does not regulate the compensation between the BLS entity and the ALS entity. If there is no agreement between the BLS ambulance supplier and the ALS entity furnishing the service, then only the BLS level of payment may be made. In this situation, the ALS entity's services are not covered, and the beneficiary is liable for the expense of the ALS services to the extent that these services are beyond the scope of the BLS level of payment. Therefore, we decided that the Plan does not have to pay for the ambulance services (CPT code A0427) provided to the enrollee on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 27, 2020, through June 7, 2020, by a non-participating provider who is not certified with Medicare.
You asked the Plan to pay for the home health services. You say that the information given to you was very misleading and you would not have chosen the company you did if you were given the correct information from the beginning. The Plan denied your request. The Plan says the services were rendered by a provider who is not under contract with the health plan and is not certified for Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 27, 2020, through June 7, 2020, by a non-participating provider who is not certified with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
You asked the Plan to pre-approve group 3 power wheelchair. You say that the enrollee has a neurological disease with residual side effects and needs this device. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not have a progressive neurological disease required for a group 3 power wheelchair. The Plan says that a basic group 2 power wheelchair would be able to meet the enrollee's needs.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity.
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 group 3 power wheelchair and accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for a group 3 power wheelchair. Our physician reviewer found the documentation does not support that the enrollee's mobility limitation impairing participation in mobility-related activities of daily living (MRADLs) is due to a neurologic condition, congenital skeletal deformity, or myopathy.
We looked at this physician's review, the file, and Medicare rules. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 genomic profile panel testing provided to the enrollee on November 5, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Thirty-two CPT codes were reported to bill for the single Guardant360 genomic panel test. Guidelines under Medicare Local Coverage Article for Billing and Coding: GUARDANT360 (A58192) require that Guardant306 panel be reported with a single code, CPT 81479. All 32 codes billed should be reported using one code, 81479, per Medicare billing guidelines. Therefore, we decided that the Plan does not have to pay for Guardant360 genomic profile panel testing provided to the enrollee on November 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck (76536).

You asked the Plan to waive the copayment for the ultrasound. You say that customer service told you that all copayments were going to be waived because of the pandemic, and you recently found that only some copayments were waived. You would like cost-share for the ultrasound to be waived because you thought you would not have one. The Plan denied your request. The Plan says diagnostic radiology services are subject to a $105 copayment. The Plan also reviewed your call logs with customer service and found that you were only informed that the copayments for office visits were being waived.

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 $105 copayment for diagnostic radiology services.

You have been asked to pay a $90.46 copayment for the ultrasound. An ultrasound falls within the diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck (76536).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays you received on November 2, 2020.
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says this is not a covered
benefit.
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 services are not among
those covered under this benefit. The Plan covers only cleanings, oral exams, and bitewing x-rays. Intraoral xrays
are not covered. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays you
received on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider.

You asked the Plan to waive the copayment for lab work. You say that this should be a zero copayment The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for outpatient diagnostic tests/laboratory tests.

You have been asked to pay $9.71 which is less than your copayment amount of $10 for lab work. The correct copayment has been applied to the lab work that was provided. Lab work falls within the outpatient diagnostic tests/laboratory 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 copayment for lab work provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided to the enrollee by an out-of-network
provider.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were not
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 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 office visit provided to the enrollee by an out-of-network
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental filling you received on December 1, 2020.
You asked the Plan to pay for the filling. The Plan denied your request. The Plan says the benefit limit has been reached.
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 services are subject to a benefit limitation. The Plan covers dental extractions and fillings up to $200 per year. The records show that the $200 maximum benefit was reached with the services you received on November 12, 2020. The requested filling exceeds the $200 benefit limit. Therefore, we decided that the Plan does not have to pay for the dental filling you received on December 1, 2020.