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

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 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 physical exam of the
abdomen is negative. There is no elevated white blood cell count (WBC) in the chart. The likely diagnosis is
opioid-related constipation. The results are unknown from the colonoscopy thirty years ago. The recent
Cologuard test was apparently negative. There is a notation stating colonoscopy was done on 6/14/21. There
are no results from this. Without these results, it is not possible to assess the medical necessity of the requested
CT scan.
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 CT scan of the abdomen and pelvis
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on February 16, 2021.
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 procedure codes were not billed with the required modifier.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of
the PC of radiology services when furnished in a different payment locality than the TC.
We looked at the file and Medicare rules. The file shows that the services at issue were not billed with the
required -26 modifier to allow for separate payment of the physician component. 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 testing services rendered on February 16, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab and Regorafenib for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary for the treatment of
metastatic colon cancer. The Plan denied your request. The Plan says this is not supported by the guidelines.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 drugs. Our reviewer says that the
requested drugs are not medically reasonable or necessary. Our physician reviewer found Nivolumab and
Regorafenib appear as an abstract in a phase 2 study in JCO, and a phase 1b in JCO in June 2020. Neither of
these can be used to approve. These citations are needed as an article, not an abstract. There is no compendia
support for this drug combination.
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 drugs have not been met. Therefore, we decided that the Plan does not have
to pre-approve Nivolumab and Regorafenib for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 26, 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 55214 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 52214 is cystourethroscopy, with fulguration (including
cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands.
We find that CPT code 52214 is not supported in the medical record. Specifically, there is no documentation of
a cystourethroscopy with fulguration of trigone.
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 surgical services rendered on February 26,
2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 2021.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from January 16, 2021 to February 8, 2021.
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 claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB 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 home health services rendered from January 16, 2021 to February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on February 22, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you were taken to the hospital because you had the Coronavirus, so you would like this claim paid. The Plan denied your request. The Plan says this copayment was charged 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 $205 copayment for ambulance services. 

You have been asked to pay a $205 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (83516, 83520, 86332, 86353, 86356, 88184, 88185, 88230, 88240, 88241, 88346, 88350) provided on March 5, 2021.

You asked the Plan to pay for laboratory services. You say that this is a covered service. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (83516, 83520, 86332, 86353, 86356, 88184, 88185, 88230, 88240, 88241, 88346, 88350) provided on March 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for complete ultrasound examination of the breast (76641)
provided December 14, 2020.

You asked the Plan to pay for the diagnostic services. You say that the enrollee had multiple exams on this date
of service. Attached reports to support the level of service. Please reconsider for processing. The Plan denied
your request. The Plan says the Plan has already paid for the services on check dated January 18, 2021.

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 76641 is complete ultrasound examination of the breast.

We find that CPT code 76641-26, RT is not supported in the medical record. Specifically, the records show that
the Plan had already paid for CPT code 76641-26, RT on check dated January 18, 2021. Based on this
information, we decided that Medicare rules for coverage of the diagnostic services have not been met.
Therefore, we decided that the Plan does not have to pay for complete ultrasound examination of the breast
(76641) provided December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on April 22, 2021.

You asked the Plan to pay for the bitewing x-rays. You say that these x-rays were important to find out why your tooth was hurting. The Plan denied your request. The Plan says that you have exceeded frequency limits set in the subscriber agreement.

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 bitewings x-rays once per plan year. 

We looked the file and Plan rules. The file indicates the Plan covered bitewing x-rays for the date of service of March 10, 2021. Based on this information, we decided that the Plan's rules for coverage of the bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the hospital failed to obtain the authorization and the doctor should not be held accountable. The Plan denied your request. The Plan says no prior authorization was 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 subsequent nursing facility care provided on November 17, 2020 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 services (01480) provided on February 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

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 services. Our reviewer says that the number of units billed is not supported by the records provided. Our reviewer found that the documentation does not clearly document start and stop time of the anesthesia services provided to confirm 178 units billed. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (01480) provided on February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging provided on May 1, 2021.

You asked the Plan to pay for the PET/CT scan. You say that the PET/CT scan was medically necessary. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure, which should be rebilled using an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with appropriate diagnosis codes. 

We looked at the file and Medicare rules. The records show that the PET/CT scan in dispute was billed with diagnosis code C43.9, which represents malignant melanoma of skin, unspecified. This diagnosis code is not on the list of diagnosis codes that Medicare has deemed appropriate to bill with a PET scan.

Based on this information, we decided that Medicare rules for coverage of the PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging provided on May 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the 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 laboratory testing provided on December 8, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services rendered on August 4, 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 the services are not covered.

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 92004 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 these
services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services
rendered on August 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 5, 2021.
You asked the Plan to pay for home health services. You say that this should be covered as in-network. The Plan denied your request. The Plan says this was not billed with the correct type of bill.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted with an incorrect type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021.

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 billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) (20552), the hospital outpatient clinic visits (G0463), and the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610) provided on February 8, 2021 and March 25, 2021.
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 $365 copayment for surgery services provided at an outpatient hospital.
You have been asked to pay $617.94 ($308.97 copayment x 2 days) for the surgery services provided at the outpatient hospital. This is the Plan's allowed amount for these services which is less than the applicable copayments. 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 injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) (20552), the hospital outpatient clinic visits (G0463), and the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610) provided on February 8, 2021 and March 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from January 1, 2021, to January 19, 2021.

You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you were told there would be no patient responsibility for these services. You said that had you known there would be cost sharing, you would have had the enrollee discharged prior to incurring liability. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan also says that there are no phone records showing that you were provided with incorrect cost sharing information.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20, and a $184 copayment per day for days 21-35, and a $0 copayment per day for days 36-100 for skilled nursing facility services. 

Records show that the enrollee was in the skilled nursing facilty from December 17, 2020, to January 19, 2121, for a total of 33 days. The enrollee was charged $0 for days 1-20. For the remaining 13 days, the enrollee was charged a $184 copayment per day, for a total of $2392. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from January 1, 2021, to January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) provided April 27, 2021.
You asked the Plan to pay for the bitewing x-ray. You say that the x-rays were necessary. The Plan denied your request. The Plan says you previously received bitewing x-rays causing the requested service to exceed the Plan's frequency limits.
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 bitewing x-rays once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were previously covered on April 22, 2021. Based on this information, we determined that the Plan's frequency limit for the bitewing x-ray has been exceed. Therefore, we decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) provided April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J7999, J3411, J3415, J3490) provided on November 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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. 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 services. Our reviewer says that the use of codes J7999, J3411, J3415, and J3490, is not supported by the records provided. Our reviewer found that for code J7999, the documentation submitted did not include documentation of which drugs were used to create the compounded drug, therefore this code cannot be confirmed. For codes J3411, J3415, and J3490, the documentation supports that a "nutri-pharmaceutical blend" was given, therefore these codes should not be reported separately.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (J7999, J3411, J3415, J3490) provided on November 19, 2020.