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

We decided that the Plan does not have to pay for genetic screening testing provided by Propath Services on August 2, 2019.
You asked the Plan to pay for genetic tests. You say that these tests were ordered by the treating physician. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the diagnosis listed and were performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided by Propath Services on August 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis.
You asked the Plan to pre-approve Lucentis. The Plan denied your request. The Plan says that they did not receive documentation or medical records supporting the medical necessity for a step therapy exception.
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 Lucentis. Our reviewer says that Lucentis is not medically reasonable and necessary in this case. The enrollee has not trialed bevacizumab. The documentation does not outline contraindications or reasons this medication was not considered. Our physician reviewer found that your condition does not meet criteria for coverage of Lucentis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe triamcinolone acetonide injection coded J3304 and the arthrocentesis services coded 20610 provided on July 23, 2019.You asked the Plan to pay forthe triamcinolone acetonide injection and the arthrocentesis services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes J3304 and 20610 are not supported in the medical record. Specifically, the documentation submitted does not indicate that an injection of  triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg was administered; therefore, code J3304 cannot be verified.The documentation submitted does not indicate that arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance was performed; therefore, code 20610 cannot be verified.Based on this information, we decided that Medicare rules for coverage of the triamcinolone acetonide injection and the arthrocentesis services have not been met.Therefore, we decided that the Plan does not have to pay forthe triamcinolone acetonide injection coded J3304 and the arthrocentesis services coded 20610 provided on July 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy (PT) services rendered to you from September 16, 2019 to September 30, 2019.You asked the Plan to waive the copayments forthese services. You say that you do not feel liable for the charges.The Plan denied your request. The Plan says the copayments were applied 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 $40 copayment for each in-network Medicare-covered therapy visit. Review of the file shows that you had six PT visits from September 16, 2019 to September 30, 2019. You have been asked to pay a $40 copayment for each visit for these services, for a total of $240. These services fall within the in-network Medicare-covered therapy visit 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 copayments forthe physical therapy (PT) services rendered to you from September 16, 2019 to September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.The enrolleeasked the Plan to pay forthe ambulance services. Hesaidthat he went to sleep and his son could not initiallywake him. He said that hedid not see anambulance or paramedic and wasnot treated or assessed. He said that heshould not be charged because hedid not receive any services from the ambulance company.The Plandenied hisrequest. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 23, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets IRF admission criteria.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The enrollee's rehabilitation needs can be provided at home with home health care services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 22, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hernia repair surgery (49505) provided on June 4, 2019.
You asked the Plan to pay for the hernia repair surgery. You say that you would like reconsideration as this provider rendered the original surgery and is the only provider in the area able to perform this service. The Plan denied your request. The Plan says services from Medicare opt-out providers are not covered under your Plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. The provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for hernia repair surgery (49505) provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 18, 2019 by out of network provider, "the doctor".You asked the Plan to pay forphysician services. You say that according to R&C allowances as the provider could not refuse care.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that referring provider was a non-participating nursing facility.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 has network providers available who can provide the items/services at issue in thisappeal. 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 forthe medical services provided on July 18, 2019 by out of network provider, "the doctor".
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from July 29, 2019 to November 7, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that the physical therapy visits should be covered in full because they were prescribed as a part of your post-surgery treatment. The Plan denied your request. The Plan says you have been charged 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 $35 copayment per day for Medicare-covered in-network physical therapy services. You have been asked to pay a $35 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows you had 18 physical therapy visits. ($35 x 18 = $630).
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 physical therapy visits provided from July 29, 2019 to November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (74177 and 71260) provided on July 15, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, followed by the manifestation. In this case, J91.0 is a manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (74177 and 71260) provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services and office visit provided on August 22, 2019, August 29, 2019, September 5, 2019 and September 12, 2019.
You asked the Plan to waive the copayments for the laboratory services and office visit. You say that you were informed you would only be charged when you see the doctor. You say that you were not informed you would be charged for lab draws. The Plan denied your request. The Plan says the copayments applied 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 $50 copayment for diagnostic procedures and tests at all locations of service and a $45 copayment for visits to in-network specialists. You have been asked to pay $8.98, which is less than the standard $50 copayment for each laboratory service. The total amount you owe for laboratory services is $26.94 ($8.98/service x 3 services = $26.94). You have also been asked to pay a $45 copayment for the office visit. The total amount you owe is $71.94 ($26.94 + $45 = $71.94).
The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the laboratory services and office visit provided on August 22, 2019, August 29, 2019, September 5, 2019 and September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 6, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a hospital outpatient clinic visit (G0463)
provided on August 12, 2019.
You asked the Plan to waive the deductible for a hospital outpatient clinic visit. You say that you were not told
that this service would have a cost-share. The Plan denied your request. The Plan says this service processed
correctly.
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 $600 deductible for in-network and out-of-network services with
limited exceptions.
The item or service you asked the Plan to waive the deductible for is not listed as a service the deductible does
not apply to. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $600
deductible for in-network and out-of-network services with limited exceptions. This cost sharing is a
contractual obligation that had not been met at the time a hospital outpatient clinic visit was received on August
12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a hospital outpatient
clinic visit (G0463) provided on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 29, 2019 to August 17, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid and proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 29, 2019 to August 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on July 3, 2019.
You asked the Plan to pay for the services. You say that this should be reviewed for payment. The Plan denied your request. The Plan says the denied code has an assistant surgery indicator of 1, which means that an assistant surgeon is not allowed.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 63688. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of erupted tooth requiring removal of bone and/or sectioning of tooth of tooth #5 provided on September 5, 2019.
You asked the Plan to pay for the additional extraction. You say that you were under the impression that you had $2,500 of insurance coverage to have dental work done. You also say that you had 3 teeth pulled and did not know that your insurance only covered 2 extractions per year. The Plan denied your request. The Plan says you do not meet the conditions for approval of 1 additional extraction because you exceeded the number of allowed extractions for the time period stated in your Evidence of Coverage.
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, extractions are limited to two procedures per calendar year. The record shows that you received 3 extractions on September 5, 2019, the Plan paid for 2 of them, and your extraction benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the extraction of erupted tooth requiring removal of bone and/or sectioning of tooth of tooth #5 provided on September 5, 2019.