Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 15, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because the immunologist could not treat you. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted by Medicare rules). You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows your skin condition was evaluated at the specialist office visit.
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 specialist office visit provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the custom oral surgical splint rendered on August 20, 2020.
You asked the Plan to pay for these services. You say that this was not a dental procedure. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that temporomandibular joint (TMJ) services are not covered; however, these services may be covered when considered medically necessary to treat a medical condition. The Plan has not provided any documentation to support that the services were entirely dental in nature and not medically necessary. Therefore, we decided that the Plan has to pay for the custom oral surgical splint rendered on August 20, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Hyaluronan or derivative, gel-one, for intra-articular injection, per dose (J7326) provided on November 18, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service 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 20% coinsurance for the total cost of Part B drugs purchased at a pharmacy, administered by a pharmacist, or administered by a health care professional.
You have been asked to pay $487.60 ($2,438 x 20% coinsurance) for the Medicare Part B drug administered. 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 Hyaluronan or derivative, gel-one, for intra-articular injection, per dose (J7326) provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), endodontic therapy (D3330), and endodontic procedure (D3999) provided on March 16, 2021 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, endodontic therapy, and endodontic procedure. You say that you were not advised that the treating provider was OON. The Plan denied your request. The Plan says these services were received OON, and this claim processed correctly.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), endodontic therapy (D3330), and endodontic procedure (D3999) provided on March 16, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99337) provided on March 19, 2021 by
an out-of-network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or
approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 rest home visit (99337) provided on March 19,
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic bone marrow; biopsy(ies) and aspiration(s) (CPT code 38222) provided to the enrollee on March 11, 2021, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 diagnostic bone marrow; biopsy(ies) and aspiration(s) (CPT code 38222) provided to the enrollee on March 11, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87798, 86141, 83090, 84481, 84550, 85025, 86328, 87486, 87581, 83615, 84144, 84270, 84402, 84403, 80053, 82248, 82533, 82627, 82670, 82746, 87633, 84443, 84478, 82977, 83036, 83718, 84439, 82306, 82465, 82728) provided to the enrollee on July 21, 2020.
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 the services are not supported by the records.
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 laboratory services have not been met. CPT code(s): 87798, 86141, 83090, 84481, 84550, 85025, 86328, 87486, 87581, 83615, 84144, 84270, 84402, 84403, 80053, 82248, 82533, 82627, 82670, 82746 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on July 21, 2020, and received by the lab on July 22, 2020; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87798, 86141, 83090, 84481, 84550, 85025, 86328, 87486, 87581, 83615, 84144, 84270, 84402, 84403, 80053, 82248, 82533, 82627, 82670, 82746, 87633, 84443, 84478, 82977, 83036, 83718, 84439, 82306, 82465, 82728) provided to the enrollee on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cologuard screening (CPT code 81528) provided on
April 4, 2021.
You asked the Plan to pay for the Cologuard screening. You say that you had this test done to determine if a
colonoscopy was required because you had rectal bleeding and wanted to determine if cancer was the possible
cause. The Plan denied your request. The Plan says the maximum benefit has been paid. 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 Cologuard screening have not been met. Review of the file shows that previously had
a Cologuard screening on February 12, 2019, which was paid by the Plan with $0 cost-share to the member.
You had a second Cologuard Test (CPT 81528) on April 14, 2021, which was denied by the Plan as maximum
benefit has been paid. Therefore, we decided that the Plan does not have to pay for the Cologuard screening
(CPT code 81528) provided on April 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmented sleeves (E0669).
You asked the Plan to pre-approve the pneumatic compression device and sleeves. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Since the compression device is not covered, the requested sleeves are also non-covered. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmented sleeves (E0669).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on August 4, 2020.
You asked the Plan to pay for the drug testing services. You say that this was medically necessary and should be reimbursed. The Plan denied your request. The Plan says the POS code reported on this claim is not supported.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. The record reflects that this sample was taken in a doctor's office on August 4, 2020 and was not received by the laboratory until days later. As such, POS code 81 is not supported in this case. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 9, 2021.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease.
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 your request, the file and Medicare rules. Based on this information we decided that Medicare criteria for coverage have not been met. Specifically, cardiovascular risk assessment must be billed with CPT codes 80061, 82465 and 84478. Additionally, the documentation submitted does not include any clinical information to determine why this testing was ordered or how it will affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 9, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory 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 that a review was not completed timely.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan forwarded this case to MAXIMUS for failure to provide a timely secondary determination; however, there is no documentation of a clear denial reason for these services. There is no supporting documentation or explanation as to why procedure codes 87634 and 87640 were initially denied. Therefore, we decided that the Plan has to pay for the laboratory services rendered on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing / panels (CPT code(s): 81407, 81408, 81479) provided to the enrollee on January 29, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing / panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the available clinical case notes and records presented for an appeal of cardiovascular-respiratory risk assessment testing has been completed. Medicare denies coverage for all cardiovascular risk assessment testing / 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-respiratory risk assessment testing / panels (CPT code(s): 81407, 81408, 81479) provided to the enrollee on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing / panels (CPT code 81404) provided to the enrollee on January 28, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing / panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the available clinical case notes and records presented for an appeal of cardiovascular-respiratory risk assessment testing has been completed. Medicare denies coverage for all cardiovascular risk assessment testing / 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-respiratory risk assessment testing / panels (CPT code 81404) provided to the enrollee on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing / panels (CPT code 81404) provided to the enrollee on January 21, 2021.
You asked the Plan to pay for the testing. You say that the service was necessary based on the enrollee's medical condition. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing / panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the available clinical case notes and records presented for an appeal of cardiovascular-respiratory risk assessment testing has been completed. Medicare denies coverage for all cardiovascular risk assessment testing / 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-respiratory risk assessment testing / panels (CPT code 81404) provided to the enrollee on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing/panels (CPT code(s): 81404, 81407, 81408) provided to the enrollee on January 11, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing / panels. 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 testing have not been met. Review of the available clinical case notes and records presented for an appeal of cardiovascular-respiratory risk assessment testing has been completed. Medicare denies coverage for all cardiovascular risk assessment testing / 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-respiratory risk assessment testing/panels (CPT code(s): 81404, 81407, 81408) provided to the enrollee on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided to the enrollee on August 13, 2020.
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 the services are not supported by the records.
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 laboratory services have not been met. CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an assisted living facility POS 13. Also, the laboratory results submitted indicate the specimen was collected on August 13, 2020, and received by the lab on August 14, 2020. Of note, the patient resides in LA and the billing laboratory is located in GA; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided to the enrollee on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 15, 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 laboratory services provided on February 15, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code
81455) provided to the enrollee on January 15, 2021.
You asked the Plan to pay for the testing. You say that this was ordered by the treating physician because the
test result was needed to help determine the course of treatment for this enrollee. The Plan denied your request.
The Plan says this is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
Targeted genomic sequence analysis panel, Targeted genomic sequence analysis panel, solid organ or
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes, (CPT code
81455) is non-covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to
impact therapeutic decision-making in the clinical management of the patient and will be denied automatically
as not medically necessary and screening testing. Therefore, we decided that the Plan does not have to pay for
the targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on January 15, 2021.