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

We decided that the Plan does not have to pay for the chest x-ray.

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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 chest x-ray.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for microslide consultation (88321).

You asked the Plan to pay for microslide consultation. You say that this is separately payable. The Plan denied your request. The Plan says this service has already been paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that an additional unit of CPT code 88321 are not supported in the medical record. The medical record only supports 1 unit of CPT code 88321, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of microslide consultation have not been met. Therefore, we decided that the Plan does not have to pay for microslide consultation (88321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services
should be billed to Original Medicare.

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 the medical services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home modifications, ramp (S5165).

You asked the Plan to pre-approve a ramp. You say that you believe it would be in the enrollee's best interest to be provided with some ramp assistance to prevent the risk of falling. The Plan denied your request. The Plan says the requested ramp is not medically necessary.

The Plan must follow Medicare rules. 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 a ramp. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested ramp does not meet the criteria of Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The ramp exceeds the patient's medical needs as the patient can ambulate and is able to negotiate stairs with family support.

We looked at this physician's review, the file, and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item 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 a ramp have not been met. Therefore, we decided that the Plan does not have to pre-approve home modifications, ramp (S5165).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with accessories.

You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested item is appropriate for the enrollee to utilize daily in order to complete her mobility-related activities of daily living. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. Medicare rules say that a Group 3 power wheelchair is covered when certain criteria, detailed in the Medicare rules section of this letter, are met.

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 a Group 3 power wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does reveal that the enrollee's mobility limitation is due to a neurological condition of a stroke. However, the enrollee does not meet the coverage criteria for a power tilt and recline seating system. The enrollee is not at high risk for development of a pressure ulcer and is able to perform a functional weight shift. The enrollee does not utilize intermittent catheterization for bladder management. The patient does not use a ventilator. The power seating system is not needed to manage increased tone or spasticity. The coverage criteria for the requested Group 3 power wheelchair with multiple power options are not met. As the requested wheelchair is not appropriate, the requested accessories are also not medically 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 a Group 3 power wheelchair have not been met. As the requested wheelchair is not appropriate, the requested accessories are also not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an expanded pharmacology panel provided to the enrollee on
July 28, 2020.
You asked the Plan to pay for the panel. You say that this was medically necessary. The Plan denied your
request. The Plan says if a single procedure is performed, only one HCPCS/CPT code with one unit of service
may be reported for the procedure.
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 panel. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found no provider records have been submitted for review. Therefore, there is no evidence to support that the
provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the
enrollee's condition.
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 panel have not been met. Therefore, we decided that the Plan does not have
to pay for an expanded pharmacology panel provided to the enrollee on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional
periapical x-ray (D0230).

You asked the Plan to pay for the dental services. You say that the services are necessary to determine decay,
damage or injury to your teeth. You say that by the Plan not paying for these services is a failure of the
insurance carrier to provide preventive and/or routine dental services as offered by the plan. You also say that
this indicates that the insurance carrier does not want you to maintain proper oral hygiene and stay healthy. The
Plan denied your request. The Plan says periapical x-rays are not listed as covered services.

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. The Evidence of Coverage clearly states that any services not listed are
not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220)
and the additional periapical x-ray (D0230).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 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 diagnostic radiology services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).

You asked the Plan to pay for the neuromuscular stimulator. You say that this service was medically necessary
for the enrollee. The Plan denied your request. The Plan says the neurostimulator was not medically necessary
for the enrollee's condition.

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 neuromuscular stimulator. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found a physical examination of the lower extremities would reasonably be required to
adequately assess whether the coverage criteria were met. The documentation does not support that the
neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient
documentation of a credible evaluation and physical examination of the knees.

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 neuromuscular stimulator have not been met. Therefore, we decided that the
Plan does not have to pay for the neuromuscular stimulator (E0745).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management.

You asked the Plan to pay for the hospital discharge day management. You say that you would like this claim
to be reconsidered for payment. 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 enrollee'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 the hospital discharge day management.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received from an out-of-network provider.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says you are responsible for payment.

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 services require a greater cost share when provided by an out-of-network provider. The Plan paid the allowed amount for each of the services in question. However, the amount billed by the out-of-network provider was greater than the allowed amount. This means that you are responsible for the amount in excess of the allowed amount paid by the Plan. Therefore, we decided that the Plan does not have to pay for the dental services you received from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Fasenra injection (J0517, 96372).

You asked the Plan to waive the coinsurance for the Fasenra injection. You say that the cost of the injection is too high. The Plan denied your request. The Plan says the coinsurance was 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% of the total cost for other Medicare Part B drugs.

You have been asked to pay a total of $1020.67 for the October Fasenra injection ($5,103.36 allowed amount x 20%). Fasenra injections fall 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 Fasenra injection (J0517, 96372).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a total knee arthroplasty, radiologic exam and basic
metabolic panel.

You asked the Plan to pay for the total knee arthroplasty, radiologic exam and basic metabolic panel. The Plan
denied your request. The Plan says the Plan requires utilization of network providers when possible and
available and requires authorization for certain services. No medical necessity for an out-of-network provider,
such as an urgent or emergency situation, has been documented.

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
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 a total knee arthroplasty, radiologic exam and basic metabolic
panel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311).

You asked the Plan to pre-approve an electronic connection. You say that the enrollee needs this item. The Plan denied your request. The Plan says there is no medical need for this item.

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 an electronic connection. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the patient requires other types of proportional input devices or non-proportional input devices. The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The documentation reveals the patient's upper body strength and function should be able to control any power option through their individual switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician services.

You asked the Plan to waive the deductible for the physician services. You sent your bill in for review. The
Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $198 deductible and a $1,408 deductible that applies towards innetwork
physician services.

The physician services you asked the Plan to waive the deductible for falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules
by clearly disclosing in the contract that there is a $198 deductible and a $1,408 deductible that applies towards
in-network physician services. This cost sharing is a contractual obligation that had not been met at the time the
physician services were received. Therefore, we decided that the Plan does not have to waive the deductible for the physician services provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation does not support the coding criteria, and does not support 22 or more drug classes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of the denied codes is:

CPT 82570:

Creatinine

CPT 81003:

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents

HCPCS G0483:

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the lab report does not support 22 or more drug classes were performed on this date of service.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee.