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

We decided that the Plan does not have to waive the copayment for the cardiovascular stress test provided on February 21, 2020.
You asked the Plan to waive the copayment for the cardiovascular stress test. You say that you should not be responsible for the copayment because the service is a part of your pre-op for your surgery. 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 $20 copayment for Medicare-covered outpatient diagnostic procedures and tests. You have been asked to pay a $20 copayment for the cardiovascular stress test. The cardiovascular stress test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a pre-operative service to a surgical procedure.
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 cardiovascular stress test provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a ramp to the house, a roll in shower, raised toilet seat, startup
and renovation cost on April 17, 2019.
You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied
your request. The Plan says the ramp would be considered a convenience item, the roll in shower and toilet seat
would also be convenience items primarily hygienic in nature, thus all of these items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for a ramp to the house, a roll in shower, raised toilet seat, start-up
and renovation cost on April 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on January 24, 2020.
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says that the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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 pathology services provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a phlebotomy provided on January 7, 2020.
You asked the Plan to reimburse you for the phlebotomy. You say that these treatments are medically necessary to avoid another stroke. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires 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 reimburse you 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 reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for a phlebotomy provided on January 7, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that the requested Ilumya is medically necessary. The Plan denied your request. The Plan says that the requested Ilumya is not medically necessary.
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 Ilumya. Our reviewer says that the requested Ilumya is medically necessary. Our physician reviewer found the enrollee has a diagnosis of Psoriasis vulgaris. She has moderate to severe plaque psoriasis with severe itching and significant erythema. The enrollee has failed to respond to multiple therapies. The enrollee's physician attests to the fact that the enrollee does not have active TB or other serious infections. The requested use of Ilumya is FDA-approved for the enrollee's diagnosis. The documentation supports that Ilumya is expected to be safe and effective and otherwise 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 Ilumya have been met. Therefore, we decided that the Plan has to pre-approve Ilumya.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel of 15-21 drug classes
provided on January 15, 2020.
You asked the Plan to pay for the definitive drug panel. You say that this medically necessary testing should be
covered. The Plan denied your request. The Plan says the order does not clearly document the testing being
requested.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the
enrollee's treating physician.
Although there is a signed order in the file, it does not clearly indicate the panel being requested or that the
custom profile is the panel intended by the ordering provider. Therefore, we decided that the Plan does not
have to pay for the definitive drug testing panel of 15-21 drug classes provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pre-approve a Group 2 Pressure Reducing Support System. You say that The Plan denied your request. The Plan says the enrollee does not have any pressure ulcers.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules fo rcoverage of a Group 2 Pressure Reducing Support System have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Group 2 Pressure Reducing Support System.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection for respiratory virus testing rendered on December 16, 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 testing is not covered.
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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent a nasopharyngeal swab was obtained on 12/16/20 for Influenza A, Influenza B, and RSV. The case file contains a lab requisition and results. Diagnoses of Cough and Fever, unspecified are listed. There are no clinical records in the case file. The documentation is insufficient to demonstrate that infectious agent detection for respiratory virus is the standard of care for the enrollee's condition and was medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection for respiratory virus testing rendered on December 16, 2019.
The Local Coverage Article (LCA) referenced by the Plan is not valid for Part B Medicare for the state of Pennsylvania where the testing was performed and was not used in the MAXIMUS determination.
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 your needs cannot be met at a lower level of care.
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 your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does
not currently require the intensive physician and nursing oversight only in an IRF. While you may benefit from
additional multiple therapies of physical therapy and occupational therapy, you do not require an intensive
rehabilitation therapy program provided in an IRF.
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (Q0092, 71046, R0070) provided on January 24, 2020.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 radiology services (Q0092, 71046, R0070) provided on January 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 71045 provided on January 30, 2020.
You asked the Plan to pay for CPT code 71045. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. In this case, CPT code 71045 is a column two code and cannot be billed with column one code, 32557. Therefore, we decided that the Plan does not have to pay for CPT code 71045 provided on January 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (70490, 99284) provided March 25, 2020. You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived due to dental offices being closed. The Plan denied your request. The Plan says the services were rendered in the emergency room, and therefore the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room Services. The Emergency Room Services fall 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 Emergency Room Services (70490, 99284) provided March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Intraoral - periapical each additional x-ray (D0230) provided February 25, 2020.
You asked the Plan to pay for the dental service. You say that your coverage indicates prophylaxis and bitewing x-rays are covered and you feel that they should be allowed. Three x-rays were needed for the dentist to do a thorough examination. The Plan denied your request. The Plan says this request exceeds the benefit frequency limitation.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that 1 intraoral x-ray is covered per year. The plan approved for an intraoral x-ray for this date of service. Therefore, the additional x-ray is not covered. 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 pay for Intraoral - periapical each additional x-ray (D0230) provided February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (D0270) and intraoral x-rays (D0230) provided July 24, 2018.
You asked the Plan to pay for the bitewing and intraoral x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says dental x-rays are not a covered benefit.
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 pay for bitewing x-rays (D0270) and intraoral x-rays (D0230) provided July 24, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 25, 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of sclerosant to treat veins (sclerotherapy).
You asked the Plan to pre-approve sclerotherapy. You say that you have veins that are very painful when walking but cannot afford to pay for this without insurance. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because your veins measure 0.1 millimeters(mm) to 2mm in size however approval of this procedure requires veins 3mm-6mm in size.
The Plan follows Medicare rules. Medicare rules say that sclerotherapy is only covered when the specific clinical criteria listed above are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve sclerotherapy. Our reviewer says that you do not meet the Medicare criteria for the requested sclerotherapy. Our physician reviewer found you were treated with sclerotherapy in October 2018 and returned for repeat evaluation on June 9, 2019. Overall, your legs were doing well. The bulging area on your legs appear to be lipomas. Vein size is from 0.1 millimeters(mm) to 2mm approximately. You have been using compression stockings for over 5 years, are active, and walk on a regular basis. There is no documentation that you have significant symptoms attributable to the veins requested for treatment that are limiting your mobility or activity. There has been no recent assessment of absence of deep vein thrombosis (DVT). There is no recent assessment of lower extremity arterial perfusion. Therefore, the records submitted do not support the medically necessity of the requested sclerotherapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve injection of sclerosant to treat veins (sclerotherapy).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code G0483 provided on September 10, 2019.
You asked the Plan to pay for CPT code G0483. 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. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0483 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code G0483 provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 9, 2020.
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 a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the physician services provided on November 14, 2019 by an out of network (OON) provider.