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

We decided that the Plan has to pay for the WATS 3D biopsy services provided on November 17, 2020.

You asked the Plan to pay for the biopsy services provided. You say that the ordering physician made a determination of medical necessity. The Plan denied your request. The Plan says that clinical practice guidelines do not support the clinical utility of the testing.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

We looked at the file and the rules. The enrollee was referred for the services by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. The medical records also show that the enrollee's previous testing showed positive for blood in the stool. The American Society of Gastrointestinal Endoscopy suggests using WATS-3D (brush) biopsy testing in patients with known or suspected Barrett's esophagus. Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the WATS 3D biopsy services provided on November 17, 2020.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Albuterol inhaler provided on February 19, 2021.

You asked the Plan to pay for the Albuterol inhaler. You say that you were temporarily treated with oxygen, and given 2 prescriptions. The Plan denied your request. The Plan says the Albuterol inhaler is a self-administered drug. The Plan also says that self-administered drugs are not covered services under your plan.

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 pay for the Albuterol inhaler provided on February 19, 2021.

Benefits for the Albuterol inhaler 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighteen (18) additional PT visits.

You asked the Plan to pre-approve eighteen (18) additional PT visits. You say that the additional PT is medically necessary. The Plan denied your request. The Plan says the enrollee has not made significant improvements since March 15, 2021, and the proposed treatment plan is not expected to significantly improve her condition within a reasonable and predictable time frame.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 eighteen (18) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. Her deficits and functional level do not require ongoing formal PT. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eighteen (18) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eighteen (18) additional PT visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic testing provided by a participating provider on October 20, 2020.

You asked the Plan to waive the copayment for diagnostic testing. You say that you do not agree with this copayment. 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 $50 copayment for outpatient diagnostic tests/diagnostic tests. 

You have been asked to pay a $50 copayment for diagnostic testing. The correct copayment has been applied to the testing that was provided. Diagnostic testing falls within the outpatient diagnostic tests/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 diagnostic testing provided by a participating provider on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on February 22, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was 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 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 laboratory services provided by an out-of-network provider on February 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the emergency care provided on January 11, 2021.

You asked the Plan to waive the co-payment for the emergency care. You say that the enrollee passed away so you would like the co-payment waived. The Plan denied your request. The Plan says the co-payment was charged correctly.

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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 co-payment for Emergency Care.

The enrollee had a $90 co-payment for the emergency care. The emergency care falls within the Emergency Care benefit category. This means that the correct amount was charged based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the emergency care provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on October 1, 2020.

You asked the Plan to pay for the testing services. You say that the physician ordered the test to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says providers should use CPT code 81479 at this time.

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 looked at the file and the rules. We find that the test at issue were not billed with a single procedure code. 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 Guardant360 testing provided on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the x-ray exam of the lower leg (73510) provided on February 18, 2021.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

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 a $25 co-payment for basic radiological services provided at a specialist's office, urgent care center, outpatient hospital, or freestanding radiological facility.

You have been asked to pay a $25 co-payment for the radiological service provided at an outpatient hospital.
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 co-payment for the x-ray exam of the lower leg (73510)
provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint (CPT code 64625).

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint (CPT code 64625).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an MRI scan of the brain (including brain stem) (70553) received on November 16, 2020.

You asked the Plan to waive the co-payment for an MRI scan of the brain. You say that you were told the co-payment was $195 and that is what you paid. The Plan denied your request. The Plan says the correct co-payment was applied.

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 a $275 co-payment for Medicare-covered diagnostic radiology services (not including X-rays) except for mammography and ultrasounds.

You have been asked to pay a $275 co-payment for an MRI scan of the brain. An MRI scan of the brain 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 co-payment for an MRI scan of the brain (including brain stem) (70553) received on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code 81479) provided to the enrollee on October 23, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Review of the file shows that the enrollee had cardiovascular risk assessment testing on October 23, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code 81479) provided to the enrollee on October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (00840) provided on September 13, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because this service was denied in error. The Plan denied your request. The Plan says this claim was billed with an inappropriate place of service code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Specifically, the record indicates that the member was outpatient for the billed services. This claim has been billed with an inappropriate Place of Service code for outpatient services. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00840) provided on September 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 22, 2021.

You asked the Plan to pay for the dental service. You say that you called the Plan prior to your appointment to see what was covered. You say that you were not told that only 1 exam was covered per year. You also say that this was an emergency due to excruciating pain. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on February 18, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on October 16, 2020.

You asked the Plan to pay for the testing services. You say that medical necessity has been established with lab results. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the enrollee's medical documentation

We looked at the file and the rules. The case file does not contain medical records from the enrollee's treating physician to show that the results of the testing would be used in the management of a specific medical problem. 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 testing services provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633), for the enrollee.

You asked the Plan to pre-approve the services. You say that this pain is limiting the enrollee's ability to function, and you placed an authorization to allow the procedure as the enrollee has been able to function normally since November 10, 2020. The Plan denied your request. The Plan says the requested procedure session will exceed the allowed limit of no more than two sessions per region of the enrollee's spine in twelve (12) months.

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 services. Our physician reviewer found the request exceeds utilization criteria and therefore, the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 4, 2021.

You asked the Plan to pay for foot orthotics. You say that you cannot walk without orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics)are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone and is in quite poor health. You state given the enrollee's multiple comorbidities and their acute issue with multiple rib fractures the enrollee is in no way able to be discharged home. The Plan denied your request. The Plan says the stay is not medically necessary.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic mammography, including CAD when performed, bilateral (77066) diagnostic digital breast tomosynthesis, unilateral or bilateral (G0279) provided December 23, 2020.

You asked the Plan to waive the copayment for the diagnostic services. You say that the mammogram is your yearly mammogram and was scheduled at your yearly physical as always. It was not scheduled as a part of care in connection with your breast cancer. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $50 copay for services in an Outpatient Hospital Facility.

You have been asked to pay $50 copay for the diagnostic services. The diagnostic service 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 diagnostic mammography, including CAD when performed, bilateral (77066) diagnostic digital breast tomosynthesis, unilateral or bilateral (G0279) provided December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an inpatient hospital stay provided by a participating provider on December 27, 2020, to December 29, 2020.

You asked the Plan to waive the co-payment for an inpatient hospital stay. You say that this is too high of a co-payment. The Plan denied your request. The Plan says the correct co-payment has been applied.

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 a $395 co-payment per day for days 1-4. There is a $0 co-payment for additional days for inpatient hospital care.

You have been asked to pay a $395 co-payment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $790 ($395 x 2 days = $790). An inpatient hospital stay falls within the
inpatient hospital 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 co-payment for an inpatient hospital stay provided by a participating provider on December 27, 2020, to December 29, 2020.