Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe consultation (D9310), the synthetic graft (D7995), guided tissue regeneration (D4266), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), the drugs and medicaments (D9630), the therapeutic parenteral drug (D9610), and the drainage of mouth lesion (40801) provided on March 13, 2020.You asked the Plan to reimburse you forthe dental services. You say that your dentist referred you for emergency treatment of an upper jaw infection. You say that the claim was submitted as dental but resubmitted as medical. You also say that the dental claim was denied, and the medical claimhas not yet processed for reimbursement.The Plan denied your request. The Plan says the services are dental in nature. The Plan also says that routine dental services are not covered by Medicare. 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 dental services when the services are medically necessary and reasonable. 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 reimburse you for the dental services. Our reviewer says that the dental services are not medically necessary. Ourphysician reviewer found the record indicates that the enrollee had recurrent infection and presented with a buccal canine space abscess. The reviewer found that the record supports that the services performed are dental care. The reviewer found that the services provided are not surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. Therefore, the reviewer found that the elements of the coverage criteria are not satisfied and therefore not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to reimburse you forthe consultation (D9310), the synthetic graft (D7995), guided tissue regeneration (D4266), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), the drugs and medicaments (D9630), the therapeutic parenteral drug (D9610), and the drainage of mouth lesion (40801) provided on March 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEylea.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has macular degeneration. She has not tried and failed the Plan's required drugs, Avastin, Mvasi, or Zirabev. The records do not show that the required drugs would be contraindicated or less effective; therefore, Eylea is not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveEylea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (G2025) provided on January 20, 2021, by an out of network (OON) provider.

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.

You asked the Plan to pay for telehealth services. You say that you are an in-network provider and would like this claim reprocessed. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

The requested provider in this case is not a network provider with the Plan. Although you state you are a network provider, the Plan has denied this assertion. 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 telehealth services (G2025) provided on January 20, 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 home health visit provided February 3, 2021 by an out of network (OON) provider.

You asked the Plan to pay for home health visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.

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 home health visit provided February 3, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed (E0265).You asked the Plan to pre-approvea total electric hospital bed. You say that this item is necessary for your condition.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift mechanism.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found there is no clear documentation that you have severe arthritis of the hip or a neuromuscular disease. There is no documentation that the seat lift is being ordered to improve your ability to go from a sitting to standing position or that you are completely incapable of standingfrom a chair in the home. The records show that you have the ability to ambulate. The records do not support that the seat lift mechanism is reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvea seat lift mechanism.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on March 16, 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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora catheter placement in coronary artery procedure (93455) and related implants or supplies (C1769, C1887, C1894) provided on November 25, 2020.You asked the Plan to waive the coinsurance fora catheter placement in coronary artery procedure and related implants or supplies. You say that you cannot afford this coinsurance.The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for each outpatient hospital and ambulatory surgery visit. You have been asked to pay $355.00, or less than 20% of the Medicare-allowed charge of $2,504.73, for a catheter placement in coronary artery procedure and related implants or supplies. A catheter placement in coronary artery procedure and related implants or supplies fall within the "Outpatient hospital services" benefit category. This means that you have been asked to pay less than or equal to 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 coinsurance fora catheter placement in coronary artery procedure (93455) and related implants or supplies (C1769, C1887, C1894) provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81120, 81121, 81246, 81310) provided to the enrollee on January 11, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

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 laboratory services have not been met. Review of the file shows the enrollee had molecular pathology testing on January 11, 2021. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81120, 81121, 81246, 81310) provided to the enrollee on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hereditary cardiovascular screening provided on October 23, 2020.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.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. In this case, there are insufficient medical records to show that the results of the testing would be used in the management of a specific medical problem for the enrollee. The test at issue in this appealwas requested for screening purposes. Medicare does not cover this test for screening purposes.Therefore, we decided that the Plan does not have to pay forthe hereditary cardiovascular screening provided on October 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a colonoscopy provided on March 2, 2021.

You asked the Plan to waive the deductible for a colonoscopy. You say that you thought that colonoscopies were fully covered. 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 surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

The medical records show that you received a diagnostic colonoscopy due to constipation on March 2, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. 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 $673.04.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on March 2, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora commode chair (E0163) and sales tax (S9999), provided on January 5, 2021.You asked the Plan to pay fora commode chair and sales tax. You say that the item is medically necessary.The Plan denied your request. The Plan says the provider is not included in the list of durable medical providers that serve in your area. The plan did find Medicare certified providers for the item in your area and provided you witha list.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that the provider at issue was not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's enrollment in Medicare for the date of service at issue.Therefore, we decided that the Plan does not have to pay fora commode chair (E0163) and sales tax (S9999), provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit (99283) provided on January 29, 2021.You asked the Plan to pay forthe evaluation and management service. You say that the service was medically necessary.The Plan denied your request. The Plan says the service in this case is related to the care of the care, treatment, removal, or replacement of teeth or structures directly supporting teeth. The Plan also says that this service is not covered by Medicare.Medicare generally does not The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe emergency department visit (99283) provided on January 29, 2021.cover dental services. The Plan follows the same rule.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided January 4, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you were under the impression this service would not have a copayment. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Medicare-covered eye exams. You have been asked to pay a $35 copayment for the medical eye exam. This service falls within the Medicare-covered eye exams benefit category. Although you are fully covered for a routine eye exam, the record indicates that this was an exam meant to diagnose a specific medical problem regarding your eyes. 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 medical eye exam provided January 4, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on September 4, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on September 4, 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.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 29, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on October 29, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation services provided on December 31, 2020.
You asked the Plan to pay for the initial observation services. You say that this should not require authorization as the billing provider was the on-call physician during this patient's outpatient hospital stay. The Plan denied your request. The Plan says this was not authorized. Out-of-network care must be authorized.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation to support that payment is due and that coverage criteria are met.
In this case, the evaluation was performed by a Physician Assistant. The progress note was signed by a supervising physician. However, there is no evidence that the rendering physician reported on the claim was involved in this encounter. We find that the documentation submitted does not support payment for these services to the physician noted on the claim. Therefore, we decided that the Plan does not have to pay for the initial observation services provided on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on February 26, 2021.
You asked the Plan to pay for the testing services. You say that the records show medical necessity. The Plan denied your request. The Plan says predictive screening testing is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing provided on February 26, 2021.