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

We decided that the Plan does not have to pay for the mobile x-ray services rendered on October 7, 2020.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct POS code. We looked at the file and Medicare rules. The file shows that the services were rendered in a skilled nursing facility and should have been billed with POS code 32. 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 mobile x-ray services rendered on October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092 and R0070) provided on September 17, 2020.
You asked the Plan to pay for the transportation and set up of a portable x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a SNF itself must submit all Medicare claims for the services that its residents receive.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of a portable x-ray have not been met. Specifically, this claim was billed with place of service code 31 indicating that the member was in a Part A SNF stay. In this case, these services are not separately billable to Medicare Part B. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092 and R0070) provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on March 20, 2019, by an out-of-area provider.
You asked the Plan to pay for the out-of-area services. You say that you were in Florida and sought diagnostics locally. The Plan denied your request. The Plan says your plan has no out-of-network benefits for routine services without prior authorization.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file, and Medicare rules. The services were not urgent or emergent. The need for services was known prior to leaving the service area. 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 magnetic resonance imaging (MRI) services provided on March 20, 2019, by an out-of-area provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 1, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. The Plan denied your request. The Plan says this is not a covered service.
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 cardiovascular risk assessment panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an elderly woman with diabetes and family history of atherosclerosis. Assessment of cardiovascular risk should be based on clinical factors (fasting lipid profile, in this case the presence of diabetes, hypertension, age, etc.) and a clinical risk profile created which will guide further risk factor modification and possible pharmacologic therapy based on clinical risk and published AHA/ACC guidelines for appropriate risk modification. The use of cardiovascular variant gene screening to assess risk in an elderly patient with baseline significant clinical risk factors is not medically necessary and does not meet the CMS section 1862 rule for medical reasonableness, standard of care, or medical necessity. 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 cardiovascular risk assessment panel have not been met. Please note that the Local Coverage Determinations (LCDs) referenced by the Plan are not applicable for the jurisdiction in question. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for chiropractic services provided from
September 30, 2020, through October 8, 2020.
You asked the Plan to reimburse you for the chiropractic services. The Plan denied your request. The Plan says that the Plan will not authorize reimbursement for the cost of self-referred chiropractic services provided by a non-network provider. Additionally, you are contractually required to obtain this service from network providers.
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 chiropractic services. 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 chiropractic services provided from September 30, 2020, through October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an In-vitro fertilization (IVF) procedure.
You asked the Plan to pre-approve the In-vitro fertilization procedure. You say that the service is medically necessary and should be covered. The Plan denied your request. The Plan says this procedure is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary for the treatment of an illness or injury are not covered. We looked at the file, and Medicare rules. The requested procedure is not covered under Medicare, as it is not considered a service that is necessary for the diagnosis or treatment of an illness or injury. Based on this information, we decided that Medicare rules for coverage of the In-vitro fertilization procedure. have not been met. Therefore, we decided that the Plan does not have to pre-approve an In-vitro fertilization (IVF) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 6, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that 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 $40 copayment for a specialist visit. You have been asked to pay the allowed amount of $24.65, which is less than the $40 copayment for a specialist visit. A specialist 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 a specialist visit provided on July 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemotherapy regimen of Fosaprepitant, Carboplatin, Pembrolizumab, and Paclitaxel.
You asked the Plan to pre-approve chemotherapy. You say that you prefer to give the enrollee this regimen based on available evidence from a study. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because this combination is experimental and there are other proven treatments that might help the enrollee.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 chemotherapy. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested chemotherapy regimen. Our physician reviewer found the requested use of Fosaprepitant, Carboplatin, Pembrolizumab, and Paclitaxel is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The enrollee had progression on prior immunotherapy completed January 2021. This use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chemotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy regimen of Fosaprepitant, Carboplatin, Pembrolizumab, and Paclitaxel.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on July 10, 2020. You asked the Plan to waive the copayment for a CT scan. You say that you do not agree with this copayment. You say that this as not your fault. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment for diagnostic radiology services/CT scan. You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the diagnostic radiology services/CT scan 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 a CT scan provided by a participating provider on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on November 18, 2020.
You asked the Plan to pay for the shingles vaccine. You say that you were denied the shingles shot at the pharmacy. The Plan denied your request. The Plan says the claim processed correctly.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on November 18, 2020.
Benefits for the shingles vaccine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the x-ray services provided on October 6, 2020.
You asked the Plan to waive the cost share for the services provided. You say that you thought that if x-rays were part of the office visit, there would be no charge. The Plan denied your request. The Plan says the deductible had not been met.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible. The x-rays you asked the Plan to waive the cost share for falls within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided was received on October 6, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the x-ray services provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 10, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
services were not referred by a network provider or rendered in a participating facility. We have also
determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206, 81207, and G0452.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81206, 81207, and G0452 are not supported in the medical record. Specifically, the documentation does not include a signed physician order. There are no authenticated medical records from the ordering provider documenting the treating physician had intended the clinical diagnostic testing be performed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81207, and G0452.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided August 6, 2020. You asked the Plan to pay for the fixed partial denture sectioning. You say that it is difficult to pay for the service and would like the Plan to cover it. The Plan denied your request. The Plan says the service is not covered under your dental 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 the fixed partial denture sectioning (D9120) provided August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider from July 1, 2020, to September 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 services provided to you by an out-of-network provider from July 1, 2020, to September 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider.

You asked the Plan to waive the copayment for an ultrasound. You say that this should be covered as part of your mammogram. The Plan denied your request. The Plan says the correct copayment has been 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 $100 copayment for outpatient diagnostic tests/diagnostic radiology services.

You have been asked to pay $95.09 which is less than your copayment amount of $100 for an ultrasound. Since a diagnostic ultrasound was provided, the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology 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 waive the copayment for an ultrasound provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating
provider on October 28, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that last time you got ultrasounds they
were $47 and $48. The Plan denied your request. The Plan says the correct copayment has been 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 $125
copayment for outpatient diagnostic tests/radiological diagnostic tests.
You have been asked to pay less than a $125 copayment for each ultrasound. The total amount you are being
asked to pay is $238.14 ($119.07 x 2 ultrasounds = $238.14). An ultrasound falls within the outpatient
diagnostic tests/radiological 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 an ultrasound provided by a participating provider on October 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis.

You asked the Plan to waive the coinsurance for dialysis. You say that you got this insurance so you can lower the 20%. You say that paying the extra 20% is incorrect. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP.

You have been asked to pay $65.52, which is 20% of the allowed amount for each dialysis treatment. The allowed amount for each treatment is $327.60 (20% x $327.60 = $65.52). The total amount you owe is $1,113.84 ($65.52/treatment x 17 treatments = $1,113.84).

Dialysis falls within the "Services to treat kidney disease" 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 coinsurance for dialysis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lung disorder genetic testing (81407, 81408) provided on May 22, 2020.
You asked the Plan to pay for lung disorder genetic testing. You say that this was necessary. The Plan denied your request. The Plan says this was a genetic screening service that was not indicated by the enrollee's condition.
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 rules also say that screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly effects the management of the patient may not be reimbursed.
The test at issue in this appeal, lung disorder genetic testing, was requested for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lung disorder genetic testing (81407, 81408) provided on May 22, 2020.