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

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene testing.

You asked the Plan to pre-approve the testing. You say that this is medically necessary, as your mother died of pancreatic cancer. The Plan denied your request. The Plan says there is no personal history of breast, ovarian, pancreatic or prostate cancer.

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 test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a power wheelchair.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary care is available 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 out-of-network for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on March 9, 2021.

You asked the Plan to pay for physical therapy. You say that medical records and all necessary documents are attached to consider this claim for reprocessing and payment. The Plan denied your request. The Plan says the claim cannot be processed without an Explanation of Benefits from the primary insurance carrier.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for physical therapy until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for physical therapy provided on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210, D7140) provided on March 25, 2021.

You asked the Plan to pay for extractions. You say that you thought the provider was in-network. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions have not been met. Specifically, services were provided by an out-of-network provider and are not covered. Therefore, we decided that the Plan does not have to pay for extractions (D7210, D7140) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection for a controller and cupholder for a power wheelchair.
You asked the Plan to pre-approve electrical connection and cupholder. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for these options is correct, because you are able to control your wheelchair's power options using their own switches and a cupholder is not medical in nature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 electrical connection and cupholder. Our reviewer says that the requested electrical connection is not considered medically reasonable and necessary in this case. Our physician reviewer found this device exceeds your medical needs. The documentation does not reveal that you require other types of proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Your strength and function in your extremities indicates that you can control your wheelchair's power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. The requested electrical connection is not medically necessary for you. Furthermore, the cupholder at issue in this appeal does not serve a purpose that is primarily medical in nature. A cupholder is available to the general public and would be helpful even to those who are not sick or injured. Based on this information, we decided that Medicare rules for coverage of electrical connection and cupholder have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical connection for a controller and cupholder for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the change of a cystostomy tube (51705) rendered by the outof-
network (OON) provider on March 23, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the change of a cystostomy tube (51705) rendered by the out-of-network (OON) provider on March 23, 2021.
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 clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the current acute care hospital setting or in a skilled nursing facility.
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 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 she is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH 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 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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392) and resin-based composite - three surfaces, posterior (D2393) provided February 12, 2021.

You asked the Plan to pay for the two-surface white filling and three-surface white filling. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for the resin-based composite - two surfaces, posterior (D2392) and resin-based composite - three surfaces, posterior (D2393) provided February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power-operated scooter.

You asked the Plan to pay for a power-operated scooter. You say that you would like the Plan to reprocess and approve this claim. The Plan denied your request. The Plan says the provider does not participate with the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a power-operated scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2391, D2330, and D2392) received on March 24, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 dental services (D2391, D2330, and D2392) received on March 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Regadenoson injection (J2785) and nuclear medicine studies of heart muscle (78452) provided March 23, 2021.
You asked the Plan to waive the cost share for the Regadenoson injection and nuclear medicine studies of heart muscle. You say that you should have been aware of your cost share before receiving these services. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $300 copayment for Medicare-covered diagnostic radiology services.
You have been asked to pay a total cost share of $349.87 for the Regadenoson injection and nuclear medicine studies of heart muscle ($300 copayment + $249.35 Medicare allowed amount x 20% coinsurance). The nuclear medicine studies of heart muscle falls within the Medicare-covered diagnostic radiology services benefit category and the Regadenoson injection falls within the Medicare-covered Part B drug 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 cost share for the Regadenoson injection (J2785) and nuclear medicine studies of heart muscle (78452) provided March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the skilled nursing facility (SNF) services provided from April 12, 2021, to April 27, 2021.

You asked the Plan to waive the cost share for the services provided. You say that there should be more covered days. The Plan denied your request. The Plan says the copay was applied based on your plan benefits.

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 $0 copay for days 1-20 and a $184 copay per day for days 21-100 for skilled nursing facility care.

We looked at the file and the rules. The records show that 20 days with a $0 copay were already applied to care you received. You have been asked to pay a $184 copay for 12 days for the services provided. The services fall within the skilled nursing facility 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 cost share for the skilled nursing facility (SNF) services provided from April 12, 2021, to April 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for a paramedic intercept (A0432) provided on December 13, 2020.

You asked the Plan to pay for a paramedic intercept. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says Your plan covers ambulance transportation only when you are actually transported by ambulance. Since you were not transported by this ambulance, the service is not covered by your plan.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for a paramedic intercept (A0432) provided on December 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 16, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare-covered services related or unrelated to the member's terminal condition.

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 laboratory services provided on December 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer screening services (G0103, 82306, 36415, 80184) provided on March 31, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for OON prostate cancer screening services. You say that changing plans at the beginning of the year caused a misunderstanding about your primary care physician. The Plan denied your request. The Plan says these services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for prostate cancer screening services (G0103, 82306, 36415, 80184) provided on March 31, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transportation (A0431-QL) provided on November 21, 2020.
You asked the Plan to pay for air ambulance transportation. You say that the QL modifier is a nationally recognized modifier and has been used properly in this situation. The Plan denied your request. The Plan says the claim was billed without the needed additional modifiers, QN and QM.
The Plan must follow Medicare rules. Medicare rules say that in addition to the QL modifier, providers report modifier QM or QN.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of air ambulance transportation have not been met. Specifically, the record shows that the services
were billed with a QL modifier, but without a QM or QN modifier. Therefore, we decided that the Plan does
not have to pay for air ambulance transportation (A0431-QL) provided on November 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 4, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an ultrasound on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 Medicare-covered radiological diagnostic services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound on February 4, 2021. You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the Outpatient diagnostic tests 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 the
ultrasound provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) provided on January 14, 2021.
You asked the Plan to pay for initial hospital care. You say that these services are not bundled. The Plan denied your request. The Plan says these services cannot be paid separately without a modifier.
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, we have confirmed that code 99222
has a bundled relationship with code 99223 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for initial hospital care (99222) provided on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay from December 25 through December 30, 2020.

You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that the Plan should pay an additional amount for the requested services. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 10% coinsurance for Inpatient Hospital Care. 

You have been asked to pay $812.99 for the inpatient hospital stay. This is less than the required 10% coinsurance required for Inpatient Hospital Care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay from December 25 through December 30, 2020.