Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth consultation (G0425) provided on September 14, 2019.
You asked the Plan to pay for the telehealth consultation GT. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed with an inappropriate GT modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0425 is not supported in the medical record. Specifically, it is inappropriate to bill the GT modifier on professional claims. Based on this information, we decided that Medicare rules for coverage of the telehealth consultation GT have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth consultation (G0425) provided on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from August 14, 2019 to October 9, 2019.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services provided are not chiropractic services covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. The services provided by this chiropractor are not services covered by the Plan or by Medicare. Therefore, we decided that the Plan does not have to pay for chiropractic office visits, chiropractic maintenance treatment, electrical stimulation, and self-care/home management training provided from August 14, 2019 to October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the neurostimulator insertion provided on October 4, 2019.
You asked the Plan to waive the coinsurance for the neurostimulator insertion. You say that the provider never confirmed the cost of the procedure. You say that the enrollee could have declined the procedure if the cost was known. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance per visit for outpatient surgery. The enrollee has been asked to pay $4,855.49, which is less than the standard 20% coinsurance for the neurostimulator insertion because the maximum out-of-pocket was met. The neurostimulator insertion falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that the enrollee has been asked to pay the correct amount based on the 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 coinsurance for the neurostimulator insertion provided on October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology genetic testing provided on April 18, 2019.
You asked the Plan to pay for the oncology genetic testing. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed exceed the allowed number of
units.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 0026U is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the oncology genetic testing have not been
met. Therefore, we decided that the Plan does not have to pay for the oncology genetic testing provided on
April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 5, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you could have seen your primary care physician the following Monday if you had known you would be charged a specialist 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 $35 copayment per specialist visit. You have been asked to pay a $35 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 October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you did not know the proper procedure for referrals. The Plan denied your request. The Plan says the service was performed by a doctor who is not in your plan, and prior approval was not received.
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 has network providers available who can provide 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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide for the enrollee.
You asked the Plan to pre-approve the aide. You say that this is medically necessary. The Plan denied your request. The Plan says the information documents non-skilled, self-care activities which are already received from in-home services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the aide. Our reviewer says that the requested aide is not medically reasonable or necessary. Our physician reviewer found the requested 16 visits of home health services do not meet the definition of home health aide services as per Sections Section 50.2 as the request is not clear on the hours per day and whether this is part-time or intermittent as discussed in Section 50.7. Furthermore, the patient is already authorized homemaking services therefore the request for the 16 visits of additional home health service exceeds what the patients needs per a home assessment and does not reveal that the requested services are reasonable and necessary to the treatment of the patient's illness or injury. 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 aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous Passive motion (CPM) device for use other
than knee (E0936).
You asked the Plan to pre-approve the CPM device. You say that you had reverse shoulder replacement and the
stretching machine is vital for your recovery. The Plan denied your request. The Plan says Medicare only
covers this device after certain types of knee surgery.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have
received total knee replacement surgery.
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to preapprove
continuous Passive motion (CPM) device for use other than knee (E0936).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontic evaluation and treatment to be provided by a periodontist.
You asked the Plan to pre-approve the periodontic evaluation and treatment. You say that you are at risk for eventually losing multiple teeth, which may lead to a decline in your overall health. You also say that you cannot afford the dental fee for this work. The Plan denied your request. The Plan says services received from a Periodontist are not covered.
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 covered when they are received by a periodontist. Therefore, we decided that the Plan does not have to pre-approve the periodontic evaluation and treatment to be provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 6 additional fillings (D2391) provided on December 18, 2019.
You asked the Plan to pay for 6 additional fillings. You say that the services you received were considered preventive in nature and therefore should be covered in full up to your $2,000 annual coverage. The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says 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 fillings are a covered service, the frequency limit of 2 fillings per calendar year has been exceeded. The record shows that the Plan paid for 2 fillings that you received on December 18, 2019. Therefore, we decided that the Plan does not have to pay for 6 additional fillings (D2391) provided on December 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on December 17, 2019.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that these drugs should
be covered by the Plan. The Plan denied your request. The Plan says claims for self-administered drugs must be
submitted to your prescription drug carrier.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 self-administered drugs provided
on December 17, 2019.
Benefits for self-administered drugs under Medicare Part B 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 copayment for a CT scan provided from September 4,
2019 to September 6, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford 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 $225
copayment for each advanced imaging service.
You have been asked to pay a $225 copayment for a CT scan. A CT scan 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 a CT scan provided from September 4, 2019 to September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Quantum Rehab Victory 4 wheeled scooter. You asked the Plan to pre-approve a Group 1 heavy duty power operated vehicle and accessories. You say that riding your current scooter outdoors or on uneven ground is very rough and the bumps make your back hurt. The Plan denied your request. The Plan says you do not meet weight criteria for the replacement scooter and you are requesting this model for outside use.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not meet criteria. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a Quantum Rehab Victory 4 wheeled scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on December 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that these services were provided in an assisted living facility. The Plan denied your request. The Plan says there is not referring provider on the claim. The Plan says that 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chronic care management provided on December 22, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing provided to the enrollee on April 26, 2019.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the code does not meet the associated diagnosis code relationship criteria.
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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have stage IV pancreatic cancer. Testing related to pancreatic cancer and for which there are associated treatments is considered medically necessary and reasonable.
Testing unrelated to pancreatic cancer or for which there are no associated therapies is not considered medically necessary or reasonable. The provided panel testing, inclusive of tests unrelated to pancreatic cancer and/or not associated with known therapies, was not medically necessary or reasonable to diagnose or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing provided to the enrollee on April 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the eyewear purchased on
October 9, 2019.
You asked the Plan to provide additional reimbursement for the eyewear. You say that you were told this
would be covered. The Plan denied your request. The Plan says that $200 was already applied to the claim.
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 up to a $200 allowance for eyewear.
We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum yearly
benefit of $200 for the requested services. There is no provision in the contract which would require the plan to
approve more than this amount. Therefore, we decided that the Plan does not have to provide additional
reimbursement for the eyewear purchased on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist services rendered on February 22, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you are on a fixed income. 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 a 20% coinsurance for each covered specialist office visit.
Review of the file shows that you received specialist services on February 22, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $32.63. These services fall within the covered specialist office visit 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 specialist services rendered on February 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 19, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
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 G0483 is 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 find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 28, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you should not owe a specialist copayment because you received services from a nurse. 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 $35 copayment per visit to a specialist. You received services from a provider that works under a specialist on August 28, 2019. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 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 August 28, 2019.