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

We decided that the Plan does not have to pay for the definitive drug testing services (G0482) provided on May 13, 2020.

You asked the Plan to pay for the definitive drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the enrollee is not taking any prescribed medications.

The Plan follows Medicare rules. Medicare rules say that Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, medication response, and clinical assessment, when accurate results are necessary to make clinical decisions.

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 pay for the definitive drug testing services. Our reviewer says that definitive drug testing is medically necessary to identify specific medications, such as illicit substances and metabolites. Our physician reviewer found the enrollee is not maintained on any prescribed medications reported per the clinical documentation. Since the enrollee is not taking any prescribed medications reported, the request does not appear to meet LCD guidelines for medical necessity. 

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 definitive drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services (G0482) provided on May 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient office visit (99203) provided October 27, 2020.

You asked the Plan to waive the copayment for the office visit. You say that you are asking that the 2 charges concerning the urgent care and the emergency room be dropped. In addition, you will say you do not appreciate having to go to either the urgent care or the emergency room at this time of COVID. 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 $65 copay per visit for urgently needed services.

You have been asked to pay $65 copay for the office visit. The office visit falls within the Urgently needed 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 outpatient office visit (99203) provided October 27, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the x-ray of the left hip, unilateral, with pelvis when performed; 2-3 views described by code 73502 provided on June 23, 2020.
You asked the Plan to pay for code 73502. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the medical records do not support the billing of code 73502.
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 73502 is Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views. We find that CPT code 73502 is supported in the medical record. Specifically, we received additional information directly from you that the Plan had not received. This information included medical records and an imaging report with an addendum to include sufficient detail to support that a radiological examination of 2-3 views of the left hip was performed. The billed service can now be verified. Based on this information, we decided that Medicare rules for coverage of code 73502 have been met. Therefore, we decided that the Plan has to pay for the x-ray of the left hip, unilateral, with pelvis when performed; 2-3 views described by code 73502 provided on June 23, 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 psychotherapy (CPT code 90836), and an establish office visit (CPT Code 99213) provided on December 9, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that you were not aware that the provider is out-of-network before you got the referral to see the provider. The Plan denied your request. The Plan says the services were received without prior authorization from 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. There was no evidence provided to verify if the services were referred by a network provider. 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 psychotherapy (CPT code 90836), and an establish office visit (CPT Code 99213) provided on December 9, 2020, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from November 4, 2019, to November 30, 2019.
You asked the Plan to pay for the SNF care. You say that the SNF care provided was medically necessary. The Plan denied your request. The Plan says the enrollee did not require daily skilled therapy services on an inpatient basis.
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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was a 76-year-old male with a medical history including diabetes mellitus, congestive heart failure and hypertension who was admitted to an
acute care hospital with a diagnosis of cellulitis of both lower extremities on October 28, 2019. He was treated and then discharged to a skilled nursing facility on November 4, 2019, for inpatient rehab services. At the time of discharge from the hospital the member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from November 4, 2019, to November 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nail services provided on January 6, 2020.

You asked the Plan to pay for debridement of nail services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was filed untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for debridement of nail services was not filed until January 25, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for debridement of nail services provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vaccinations received on November 2, 2020.
You asked the Plan to pay for the vaccinations. You say that this was needed after chemotherapy and a stem cell transplant. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccinations. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccinations. Therefore, we decided that the Plan does not have to pay for vaccinations received on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on June 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 a practitioner visit provided on June 27, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided on July 14, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you were told by the technician that your copayment would be $20 and you believed this provider to be in-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an ultrasound on July 14, 2020. The Medicare-allowed amount for the ultrasound is less than the set $125 copayment; therefore, you have been asked to pay the lesser amount of $108.81 for the ultrasound. Your 2020 EOC says that enrollees must pay a $125 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). 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 ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) (CPT code 76705) provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits, physical therapy, and electrical stimulation provided by a chiropractor from November 4, 2020, to November 19, 2020.
You asked the Plan to pay for office visits, physical therapy, and electrical stimulation. You say that you told the provider that you did not want to receive any treatment unless it was verified that it would be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visits, physical therapy, and electrical stimulation provided by a chiropractor from November 4, 2020, to November 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided by an out-of-network provider on November 2, 2020, to November 18, 2020.

You asked the Plan to waive the coinsurance for inpatient hospital services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the correct coinsurance 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 35% coinsurance for inpatient hospital care/out-of-network.

You have been asked to pay a 35% coinsurance of the allowed amount for inpatient hospital services. The total allowed amount is $783.32. The total amount you are being asked to pay is $274.13 ($783.32 x 35% = $274.13). Inpatient hospital services falls within the inpatient hospital care/out-of-network 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 coinsurance for inpatient hospital services provided by an out-of-network provider on November 2, 2020, to November 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 6, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says a licensed professional counselor is not eligible to enroll in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care services provided on August 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not a covered benefit.
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 nursing care services provided on August 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 8, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
he Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve is subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81407, and 81408) provided to the enrollee on July 14, 2020.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file shows the enrollee had cardiovascular risk assessment testing on July 14, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81407, and 81408) provided to the enrollee on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 16, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that you did not know that you had had this service within the last three years, and you told your dental provider that you only wanted to receive covered services. The Plan denied your request. The Plan says they paid for a panoramic x-ray for you in 2019, which is less than three plan years ago. Your benefit for this service was already exhausted, and therefore no payment can be made.
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 were provided in a frequency greater than what this benefit allows. The Plan provided documentation that they paid for a panoramic x-ray in 2019, which is less than three plan years prior to the date in question. Panoramic x-rays can only be covered once every three plan years. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on September 26, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on September 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient physical therapy and occupational therapy services provided from October 9, 2020, to December 11, 2020.
You asked the Plan to waive the copayments for the outpatient physical therapy and occupational therapy services. You say that it took 60 days to transfer the enrollee to an assistant living facility. The Plan denied your request. The Plan says the enrollee was charged the copayments 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). The enrollee's contract with the Plan clearly says that they must pay a $30 copayment per day for Outpatient Rehabilitation Services. The enrollee has been asked to pay a $30 copayment per day for the outpatient physical therapy and occupational therapy services. The outpatient physical therapy and occupational therapy services fall within the Outpatient Rehabilitation Services benefit category. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the outpatient physical therapy and occupational therapy services provided from October 9, 2020, to December 11, 2020.