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

We decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on December 30, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysaccording to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and 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.In this case, the CPT Code Manual definition of the denied codes is:HCPCS G0482: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 controlmaterial (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performedCPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479)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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the submitted records do not include a documented rationale for the submitted CPTs codes and do not include the results of the testing performed on 12/30/19. The records do not support the coding of CPT 80307 and HCPCS G0482.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the wellness allowance for services provided on January 1, 2019.
You asked the Plan to reimburse for the services. You say that the gym provided all of the documentation you would need for the fitness reimbursement and you submitted all that you have. The Plan denied your request. The Plan says they still need proof of payment in order to reimburse for the wellness allowance benefit. The Plan states examples of proof of payment include front and back of a cashed check, credit card receipts, or paid cash receipts.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because the Plan still needs proof of payment in order to reimburse for the wellness allowance benefit. The Plan states examples of proof of payment include front and back of a cashed check, credit card receipts, or paid cash receipts. Therefore, we decided that the Plan does not have to reimburse for the wellness allowance for services provided on January 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fororbitotomy services (CPT 67400) provided to the enrollee on September 3, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says procedure code 67400-LT is not supported by the medical records submitted.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 67400 is "Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy."We asked our coding 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 supportedby the medical records. Our coding reviewer found the documentation submitted was reviewed, and the documentation does not include the pathology report for the lesion excised.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay fororbitotomy services (CPT 67400) provided to the enrollee on September 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 16, 2019.
You asked the Plan to pay for the ambulance services. You say that you were in severe pain and could barely walk. The Plan denied your request. The Plan says the ambulance service was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows that you were complaining of abdominal pain for a few days, and you were ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair expandable controller with accessories (K0108) and a seat back (K0108).
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include the correct coding for the requested items.
The Plan must follow Medicare rules. Medicare rules say that there are specific codes that should be used to specify requested wheelchair accessories. We looked at the file and Medicare rules. The provider has submitted the request for the accessories using Code K0108 for all requested items. This is incorrect coding as there are specific codes that should be used to specify the requested accessories. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a wheelchair expandable controller with accessories (K0108) and a seat back (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee is not able to participate in at least 3 hours of rehab daily.The Plan must follow Medicare rules. The rules say that IRF admission is covered onlywhen 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 physician reviewer found that the enrollee is generally medically stable after a repair of a ruptured abdominal aneurysm. There are no neurological deficits or orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently the enrollee is at: standby assist for bed mobility, contact guard assist for transfers, and contact guard assist for ambulation. She needs very little therapy. While the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 5, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because the test was ordered by your provider. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for diagnostic procedures and tests provided in an outpatient hospital facility. You received an ultrasound at an outpatient hospital facility on March 5, 2020. Therefore, you are responsible to pay the allowed amount of $51.78, which is less than the $100 copayment. You have been asked to pay $51.78 for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on March 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 10, 2020 to January 29, 2020.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says the Plan is not responsible for coverage of these services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 10, 2020 to January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on February 26, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The Plansaysthis testing requires the use of CPT 81479.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 81479 is "unlisted molecular pathology procedure."We find that the various denied codes are not supported in the case file. Specifically, the testing at issue in this case requires the use of CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 28,
2020.
You asked the Plan to waive the copayment for an office visit. You say that you had a phone call with the
physician but no medical conditions were discussed and you disagree with the charges. The Plan denied your
request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10
copayment for each primary care provider visit.
The medical records show that you had an office visit on January 28, 2020. Therefore, you are responsible to
pay a $10 copayment.
You have been asked to pay a $10 copayment for an office visit. An 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 copayment for an office visit provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on February 23, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis testing should be coded with CPT 81479.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPTcode.In this case, the CPT Code Manual definition of code 81479 is "unlisted molecular pathology procedure."We find that the various denied codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on February 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthecystoscopy provided on December 12, 2019.You asked the Plan to waive the copayment forthe cystoscopy. You say that you were not charged in the past for this service. You say the copayment should be returned to you. The Plandenied 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 forthe cystoscopy provided on December 12, 2019.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that because of the enrollee's medical condition finger stick is difficult. The Plan denied your request. The Plan says criteria for a continuous glucose monitor is not met. 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. The enrollee is not insulin treated so the Medicare coverage criteria for a CGM is not met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services you received on May 7, 2020.You asked the Plan to pay forthe services. You say that you were not aware of your chiropractic benefits.The Plan denied your request. The Plan says this is not a covered benefit when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services you received on May 7, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on November 11, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved
for payment. 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 wound care provided on November 11, 2019 by an
out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation provided on January 28,
2020.
You asked the Plan to waive the copayment for chemodenervation. You say that you have never been charged
in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct 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 $270
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $270 copayment for chemodenervation. Chemodenervation falls within the
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
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 chemodenervation provided on
January 28, 2020.