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

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on September 22, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because Medicare denies coverage for all cardiovascular risk assessment testing - except the basic lipid panel - for all symptomatic patients with suspected or documented cardiovascular disease.

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 tests at issue in this appeal, genetic testing, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on September 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 22, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you feel that the service is preventative and there should be a $0 copayment. 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 $75 copayment for diagnostic radiology services. 

The medical records show that you received an ultrasound on October 22, 2020. An ultrasound is not included in breast cancer screenings and is subject to separate cost-sharing charges. Therefore, you are responsible to pay the $75 copayment. 

You have been asked to pay a $75 copayment 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 October 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing (S1015) provided on August 12, 2020.

You asked the Plan to pay for IV tubing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S1015 is not valid for Medicare purposes.

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 code IV tubing (S1015) is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S1015 has a status indicator of I. This means that CPT code S1015 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of IV tubing have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing (S1015) provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81291, 81225, 81227, 81226) provided September 10, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not payable as billed.

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 81291, 81225, 81227, & 81226 are not supported in the medical record. Specifically, per the National Correct Coding Initiative Coding Policy Manual, if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479. In this case, more than one procedure was billed. The unbundled services are not separately payable for a single genomic sequencing procedure. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81291, 81225, 81227, 81226) provided September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 30 minutes of critical care provided on June 27, 2020.

You asked the Plan to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292). You say that the Plan should pay this claim. The Plan denied your request. The Plan says an additional 30 minutes of critical care time was previously paid for and the documentation indicates a total of 90 minutes was performed.

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 99292 is Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).

We find that a second CPT code 99292 is not supported in the medical record. Specifically, the medical notes say the provider provided critical care for the enrollee for approximately 90 minutes. CPT code 99291 first 30-74 minutes was paid, and CPT code 99292 additional 30 minutes was paid. Based on this information, we decided that Medicare rules for coverage of critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292) have not been met. Therefore, we decided that the Plan does not have to pay for an additional 30 minutes of critical care provided on June 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye examination provided by an out-of-network provider on December 3, 2020.

You asked the Plan to pay for routine eye exam. You say that you have had a yearly examination for over 20 years as recommended by your internal medicine doctor. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan's routine vision network has reimbursed you the $75 allowance and you are responsible for any amount above this when using an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $75 allowance once per calendar year. Enrollees must pay any amount over the $75 allowance when using an out-of-network provider. 

We looked at the file and the Plan's rules. You were reimbursed the $75 allowance and are responsible for any amount beyond this for an out-of-network provider. Based on this information, we decided that the Plan's rules for additional payment of routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination provided by an out-of-network provider on December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on October 9, 2020, to October 21, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you did not know you would have a copayment. You also say that you did not pay a copayment for prior inpatient visits under a different plan. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $275 copayment for inpatient hospital care. Your contract with the Plan also clearly says that you must pay $0 copayment for day 7-90 for inpatient hospital care.

You have been asked to pay a $275 copayment per day for inpatient hospital care. Your total cost-share is $1,650 ($275 x 6 days = $1,650). The EOC confirms that $275 per day is the required copayment for this service. 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 inpatient hospital care provided on October 9, 2020, to October 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and care.

You asked the Plan to pre-approve SNF admission and care.. You say that the services are medically necessary.
The Plan denied your request. The Plan says the services are not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF admission and care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the patient does not require
skilled nursing services with the specialized skill, knowledge and judgement of a skilled professional nurse nor
does the documentation reveal evidence of complex wound care, new enteral feedings, or other skilled nursing
needs in an inpatient SNF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission and care have not been met. Specifically, the enrollee does not
need skilled nursing services. This means SNF admission and care is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and
care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery (23472).

You asked the Plan to pre-approve the shoulder surgery. You say that the surgical procedure is medically necessary. The Plan denied your request. The Plan says the surgery is not medically necessary.

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 pre-approve the shoulder surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no imaging studies showing advanced disease of the shoulder joint. More radiographic evidence is needed to justify the need for this surgery at this time. 

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 shoulder surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder surgery (23472).
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on October 16, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the initial nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 initial nursing facility care provided on October 16, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing radiographic images (D0272) provided on February
19, 2021.

You asked the Plan to pay for bitewing radiographic images. You say that this service should be covered. The
Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency
limit of one every 2 years.

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 bitewing radiographic images have not been met. Specifically, the record shows that you had
exceeded the frequency limit prior to this service on July 15, 2020. Therefore, we decided that the Plan does not have to pay for bitewing radiographic images (D0272) provided on February 19, 2021.
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

We decided that the Plan has to waive one of the copayments for group therapy. We decided that the Plan does not have to waive all of the copayments for group therapy.

You asked the Plan to waive the copayment for group therapy. You say that you would like this Plan to pay for this. The Plan says that the correct copayments have been applied.

We decided that the Plan has to waive one of the copayments for group therapy.

Evidence was not provided to show that the total amount owed was $440. Therefore, we decided that the Plan has to waive one of the copayments for group therapy.

We also decided that the Plan does not have to waive all of the copayments for group therapy.

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 group therapy. The total amount you are being asked to pay is $400 ($40 x 10 visits = $400). Therefore, we decided that the Plan does not have to waive the copayment for group therapy.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care provided from June 11, 2020, to July 28, 2020.

You asked the Plan to pay for the nursing care. You say that you would like to appeal these services. The Plan denied your request. The Plan says the services were obtained from a provider who is not under contract with the health plan and is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that in order to receive payment for covered items or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. The treating provider is not Medicare certified. Based on this information, we decided that Medicare rules for coverage of the nursing care have not been met. Therefore, we decided that the Plan does not have to pay for the nursing care provided from June 11, 2020, to July 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0434)
received January 8, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford
this copayment. 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 a $250
copayment for each Medicare-covered one-way ambulance trip.

You have been asked to pay a $250 copayment for the ambulance transportation. This service is considered a
Medicare-covered one-way ambulance trip. 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
ambulance transportation (A0434) received January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the aflibercept injection provided on January 12, 2021.

You asked the Plan to pay for Injection, aflibercept, 1 mg (J0178). You say that the Plan should pay this claim. The Plan denied your request. The Plan says a physician order and medical records supporting medical necessity were requested but not received.

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 J0178 is Injection, aflibercept, 1 mg.

We find that CPT code J0178 is not supported in the medical record. Specifically, there is no physician order or medical records in the case file.

Based on this information, we decided that Medicare rules for coverage of Injection, aflibercept, 1 mg (J0178) have not been met. Therefore, we decided that the Plan does not have to pay for the aflibercept injection provided on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit (K0108) for a power wheelchair.

You asked the Plan to pre-approve the transit kit for the power wheelchair. You say that the equipment is medically necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit kit (K0108) for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Lanreotide injection provided on January 19, 2021.

You asked the Plan to waive the coinsurance for the Lanreotide injection. You say that you received a letter stating the provider is out-of-network and it is not fair they have to pay a $1,643.11 coinsurance. The Plan denied your request. The Plan says you have been asked to pay 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs.

You have been asked to pay $1,643.11 which is 20% of the allowed amount for the Lanreotide injection. The allowed amount is $8,215.56. ($8,215.56 x 20% = $1,643.11). The Lanreotide injection falls within the "Medicare Part B prescription drugs" 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 the Lanreotide injection provided on January 19, 2021.