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

We decided that the Plan does not have to waive the deductible for CT scans provided on April 26, 2021.

You asked the Plan to waive the deductible for CT scans. You say that the CT scans were pre-approved and you were told that you would only owe a $150 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. 

You received CT scans on April 26, 2021. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $561.73, which is less than the $750 deductible. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time CT scans was received on April 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for CT scans provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), apicoectomy (D3425), and retrograde filling (D3430) provided on February 16, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, apicoectomy, and retrograde filling. You say that the earliest appointment that you could make with an in-network provider was just over two weeks from the onset of the symptoms. The Plan denied your request. The Plan says the treating provider does not participate in the Medicare program, and the services 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 provider that has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), apicoectomy (D3425), and retrograde filling (D3430) provided on February 16, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic manipulative treatment (98940) and outpatient office visit (99202) provided April 5, 2021.

You asked the Plan to waive the copayment for the chiropractic services. You say that a large dog rushed you while walking. You had no serious injury but knew you needed an adjustment. You went to this doctor who is highly recommended, and she helped you considerably. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 copayment for specialist's office.

You have been asked to pay $105 ($85 office visit + $20 copayment) for the chiropractic services. Office visits are not covered when rendered by a chiropractor. The services fall within the Chiropractic 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 chiropractic manipulative treatment (98940) and outpatient office visit (99202) provided April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the charges related to the Clinical Trial from December 10, 2020, to December 14, 2020.

You asked the Plan to pay for the charges related to the Clinical Trial. You say that the services should be covered. The Plan denied your request. The Plan says the services have not been billed to Original Medicare and therefore are not eligible to be reviewed for any additional reimbursement from the Plan.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pay for charges related to the Clinical Trial as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay for the charges related to the Clinical Trial from December 10, 2020, to December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on January 8, 2021 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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. 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 drug testing provided on January 8, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON services. You say that the documents validate the value of the testing. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers and authorization for certain services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 lab services provided on October 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MTHFR gene analysis services.

You asked the Plan to pre-approve MTHFR gene analysis services. You say that the enrollee's health is not getting better and there is a need to see if a blood clot is still a health risk. The Plan denied your request. The Plan says the clinical information does not support the use of MTHFR genotyping and this requested testing 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 MTHFR gene analysis services. Our reviewer says that MTHFR gene analysis services are not considered medically reasonable and necessary in this case. Our physician reviewer found a history of pulmonary embolus. The enrollee underwent a hypercoagulable work-up, however the MTHFR/homocystine evaluation was not included. There is no documentation of an elevated homocycteine level. The documentation does not support that MTHFR gene analysis would likely to impact the management and outcome of the enrollee 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 MTHFR gene analysis services have not been met. Therefore, we decided that the Plan does not have to pre-approve MTHFR gene analysis services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete series of x-rays (D0210) provided on February 9,
2021.
You asked the Plan to pay for the complete series of x-rays. You say that you only agreed to have these x-rays
done because the provider assured you that they were covered. The Plan denied your request. The Plan says
these x-rays are not covered by your dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a
complete series of x-rays (D0210) provided on February 9, 2021.
Your complaint about a potential miscommunication with a Plan-contracted provider is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on September 15, 2020.

You asked the Plan to pay for the therapeutic activities. 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that these services were performed by an occupational therapist assistant in a home health or hospice setting.

There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on September 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing for glycosylated hemoglobin (83036), cyanocobalamin (82607), and Vitamin D (82306) provided on January 27, 2021.

You asked the Plan to pay for testing for glycosylated hemoglobin, cyanocobalamin, and Vitamin D. You say that these tests should be covered. The Plan denied your request. The Plan says these tests were performed for screening purposes.

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, testing for glycosylated hemoglobin, cyanocobalamin, and Vitamin D, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for testing for glycosylated hemoglobin (83036), cyanocobalamin (82607), and Vitamin D (82306) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 15, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that your dental plan provides 100% coverage with no copayment for preventive dental services. You say that the guide does not tell you there is no coverage if medical care is obtained from an out-of-network provider. The Plan denied your request. The Plan says the services are not covered benefits when provided by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on December 1, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77003 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure).

We find that CPT code 77003 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance rendered on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET/CT scan of the brain for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary for an unexplained condition characterized by frequent presyncopal events. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET/CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has episodes of orthostatic hypotension with dizzy spells. The record does not indicate the presence of cognitive decline or dementia. The enrollee has undergone MRI/MRA imaging that revealed small posterior circulation vessels. The requested test is to evaluate the metabolic function in the posterior circulation area. The records provided do not indicate how the requested test would change management. The records provided do not provide support for the medical reasonableness and necessity, as defined by Medicare rules, of the requested service. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET/CT scan of the brain for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (96372) provided on February 4, 2021.
You asked the Plan to pay for injections. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. We find that CPT code 96372 is not supported in the medical record. Specifically, no records were submitted for the billed date of service. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (96372) provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0483 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after July 11, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and 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 pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 91-year-old female with dementia, hypertension and lumbar compression fracture. In this case, there are no identifiable skilled nursing service needs. In addition, there are also no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. In conclusion, you do 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after July 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99335) provided on February 24, 2021, by
an out of network (OON) provider.
You asked the Plan to pay for a rest home visit. You say that you are a hospitalist physician and depend upon
the hospital staff to verify eligibility and to obtain proper authorization from the member's insurance company.
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 a rest home visit (99335) provided on February 24, 2021, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve another course of Xiaflex injection.

You asked the Plan to pre-approve another course of Xiaflex injection, collagenase, clostridium histolyticum, 0.01 mg (J0775). You say that the enrollee would like additional injections to treat his medical condition. The Plan denied your request. The Plan says the enrollee has had the maximum four cycles of therapy.

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 another course of Xiaflex injection, collagenase, clostridium histolyticum, 0.01 mg (J0775). Our reviewer says that the documentation does not support that more Xiaflex is medically reasonable and necessary for this patient. Our physician reviewer found Xiaflex treatment protocol involves 2 injections of XIAFLEX per treatment cycle, up to 4 treatment cycles (for a maximum of 8 injections over approximately 24 weeks). More injections are considered investigational. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of another course of Xiaflex injection, collagenase, clostridium histolyticum, 0.01 mg (J0775) have not been met. Therefore, we decided that the Plan does not have to pre-approve another course of Xiaflex injection.