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

We decided that the Plan does not have to pay forthemolecular pathology genomic profiling services provided on March 4, 2020.You asked the Plan to pay forthe molecular pathology genomic profiling services. You say that you would like the plan to reconsidertheir denial.The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriateCPT code.We find that the molecular pathology genomic profiling not supported in the medical record. Specifically, this service was billed with various CPT codes. This testing requires the code 81479. The appropriate DEX Z-Code identifier must be entered adjacent to the CPT code 81479 in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the molecular pathology genomic profiling services have not been met.Therefore, we decided that the Plan does not have to pay forthe  molecular pathology genomic profiling services provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on November 20,
2019.
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 provider type is not payable.
The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery
when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP,
or CNS.
We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP,
or CNS. 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 assistant surgeon services rendered
on November 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from March 25, 2020 to March 30, 2020.
You asked the Plan to reduce the copayments for the physical therapy visits. You say that the services were approved but you cannot afford to pay a $40 copayment every time you go to therapy. 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 $40 copayment for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient Rehabilitation 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 reduce the copayments for the physical therapy visits provided from March 25, 2020 to March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on November 19, 2019.You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom profile.The Plan denied your request. The Plan says the documentation did not contain evidence ofa relationship with the ordering physician.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 the billed codes are not supported in the medical record. The documentation provided does not show that the physician is treating the enrollee for a specific medical problem who will use the results in the management of the specific problem. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the provider has been treating the enrollee since 2000.The Plan denied your request. The Plan says when performed by a non-participating provider, the service is not covered by the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the medical services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe perfusionist services provided on February 17, 2020.You asked the Plan to pay forthe perfusionist services. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87086 26, 87088 26, 87186 26 and 81001 26) provided on May 14, 2019.You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this claim was billed with the appropriate modifier.The Plan denied your request. The Plan says according to the Medicare Physician's Fee Schedule, the procedure codes submitted are statutory exclusions.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 87086 26, 87088 26, 87186 26 and 81001 26is not supported in the record. Specifically, the Clinical Lab Fee Schedule does not list these codes as payable with a -26 modifier. 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 forlaboratory services (87086 26, 87088 26, 87186 26 and 81001 26) provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you were unaware that the member had an HMO plan. The Plan denied your request. The Plan says prior 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 has network providers available who can provide 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 physical therapy provided on February 11, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xolair for the enrollee.
You asked the Plan to pre-approve Xolair. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that there is not enough support for Xolair for use in the treatment of bronchiectasis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Xolair. Our reviewer says that Xolair is medically reasonable and necessary for the enrollee in this case. The health plan has argued that Xolair is not approved for the treatment of bronchiectasis. However, the enrollee in this case also carries a diagnosis of aspergillosis, obstructive lung disease, asthma and seasonal rhinitis. Despite treatment for the aspergillosis, the enrollee continues to have symptoms and an ongoing elevated IgE. It is impossible to say if the symptoms and elevated IgE level are strictly due to the aspergillosis, or if they are due to the enrollee's asthma. Xolair is indicated for the treatment of allergic asthma. Studies have also shown Xolair to be beneficial in the treatment of aspergillosis. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Xolair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xolair have been met. Therefore, we decided that the Plan has to pre-approve Xolair for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump (99190) provided on February 6, 2020.You asked the Plan to pay forthe pump assembly and operation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump (99190) provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forpathology services (CPT 83880 and CPT 83735) provided to the enrollee on November 15, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe 26 modifier is not valid for these procedure codes.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 the denied codes is:CPT 83880:Natriuretic peptideCPT 83735:MagnesiumWe 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the CPT codes in question are noted on the 2019 MPFS list to have a PC/TC indicator of 9. As such, the concept or a professional and technical component to these CPT codes does not apply. Furthermore, no provider documentation has been submitted for review and no lab results have been submitted for review. Therefore, there is no evidence that a professional provided any service component related to the billed codes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theservices have not been met.Therefore, we decided that the Plandoes not haveto pay forpathology services (CPT 83880 and CPT 83735) provided to the enrollee on November 15, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950) and endodontic therapy (D3310).You asked the Plan to pre-approvethe core buildup and endodontic therapy. The Plan denied your request.The Plan says these services are not covered benefits.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 are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea core buildup, including any pins when required (D2950) and endodontic therapy (D3310).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on December 19, 2019 and December 20, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities.We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. 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 chest x-ray rendered on December 19, 2019 and December 20, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an EGD to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an EGD. You say that this is the only facility that can provide these services. The Plan denied your request. The Plan says there are in-network facilities that can provide these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an EGD to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you are not happy with the in-network orthopedist.
The Plan denied your request. The Plan says there is no benefit for out-of-network coverage unless the services
are are urgent, or cannot be provided in-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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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 this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive exam rendered on October 29, 2019.
You asked the Plan to pay for these services. You say that the services were different than the previous exam. The Plan denied your request. The Plan says you exceeded the benefit limit.
The Plan must follow Medicare rules. The rules say that an annual wellness visit is covered once every 12 months. We looked at the file and Medicare rules. The file shows that you received a preventive exam on April 30, 2019 for which the Plan approved and paid. The provider submitted a claim for a preventive exam for the date of service at issue, which was less than 12 months from your previously covered exam. Therefore, we decided that the Plan does not have to pay for the preventive exam rendered on October 29, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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 this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (HCPCS L3960) provided to the enrollee on February 19, 2020.
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of medical necessity for a shoulder/arm orthosis in the medical records provided. The documentation in the case file is insufficient to support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (HCPCS L3960) provided to the enrollee on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the LTACH admission criteria. You say that, in order to sustain a safe and sustainable discharge, LTACH is the best option of care. The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found ongoing care needs include respiratory support with oxygen supplementation and tracheostomy care, nebulizer treatments, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.