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

We decided that the Plan does not have to pre-approve the office visit with an out-of-network cardiologist.
You asked the Plan to pre-approve the out-of-network office visit. The Plan denied your request. The Plan says
in-network providers are available.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the office visit with an out-of-network cardiologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (C9752, 22899).

You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered investigational and is not covered.

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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the requested procedure to be an effective or safe treatment for 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (C9752, 22899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist visit provided on September 15, 2020.

You asked the Plan to waive the co-payment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received specialty physician services on the date of service at issue in this appeal. The Plan says that the correct co-payment has applied per your contract with the Plan.

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 $30 co-payment for specialty physician services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit on September 15, 2020. You have been asked to pay a $30 co-payment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the specialist visit provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided August 4, 2020.
You asked the Plan to pay for the tooth extraction. You say that you were not told about charge prior to services. The Plan denied your request. The Plan says this service is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided August 4, 2020.
Your complaint about charges not being explained to you and feeling that the provider billed the Plan for more services than were provided is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says A pneumatic compression device that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Plan's Medicare DME benefit.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET scan provided to the enrollee on February 18, 2021.
You asked the Plan to pay for the scan. You say that the procedure was performed at the request of the referring doctor. The Plan denied your request. The Plan says this claim should be billed with the appropriate diagnosis code for these services.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee has serological markers and CT findings highly suspicious for multiple myeloma which is a recognized diagnosis for PET imaging. A review of the ICD10 recognized codes did not show X5 as a recognized code. 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 scan have not been met. Therefore, we decided that the Plan does not have to pay for a PET scan provided to the enrollee on February 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted laparoscopy procedure provided from July 22, 2019 to July 26, 2019.

You asked the Plan to pay for the unlisted laparoscopy procedure. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the unlisted laparoscopy procedure was not filed until January 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the unlisted laparoscopy procedure provided from July 22, 2019 to July 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on September 18, 2020.

You asked the Plan to pay for the therapeutic procedure. You say that you feel the services were coded correctly. 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.

In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that these services were performed by a physical therapist assistant in a home health or hospice setting.

There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on September 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and co-payment for an outpatient surgery provided by a participating provider on January 25, 2021.

You asked the Plan to waive the deductible and co-payment for an outpatient surgery. You say that you should only be charged a 5% coinsurance for this. The Plan denied your request. The Plan says the correct charges have been applied.

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 $500 deductible and a $250 co-payment for outpatient surgery/in-network.

The item or service you asked the Plan to waive the deductible and co-payment for falls within the benefit category outpatient surgery/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible and a $250 co-payment for outpatient surgery/in-network. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery was received on January 25, 2021. The total amount you are being asked to pay is $598.58 ($348.58 deductible + $250 co-payment = $598.58). The procedure that was performed is considered an outpatient surgery.

Therefore, we decided that the Plan does not have to waive the deductible and co-payment for an outpatient surgery provided by a participating provider on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on January 25, 2021.

You asked the Plan to pay for the services provided. You say that the enrollee requested a vision exam. The Plan denied your request. The Plan says they were unable to determine whether the services were necessary.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and the rules. We find that the services at issue are not supported. In this case, there is
insufficient documentation to confirm the services were reasonable and necessary. The file shows the Plan
made multiple attempts to obtain this information, with no success. 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 vision services provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for eye examinations provided on September 3, 2020 and September 10, 2020.

You asked the Plan to waive the co-payments for eye exams. You say that you do not know why your doctor is charging these amounts when eye doctor exams are covered. The Plan denied your request. The Plan says the co-payment amounts you are being charged are correct.

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 $50 co-payment for each in-network eye exam. There were 2 visits, resulting in a total co-payment amount of $100.

You have been asked to pay $50 co-payment for each eye exam. Eye exams fall within the Vision 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-payments for eye examinations provided on September 3,
2020 and September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on January 5, 2021.

You asked the Plan to pay for the services provided. You say that the provider rendered the services in good faith. The Plan denied your request. The Plan says the testing was not approved by the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and the rules. The documentation in the case file shows that the ordering physician on the claim did not authorize or order the testing at issue. All diagnostic tests must be ordered by the physician who is treating the enrollee. We find that testing is not supported in the medical record. 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 genetic testing services provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 15, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing is not currently recommended for general risk stratification and would not be considered 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter ramp (A9270).

You asked the Plan to pre-approve a scooter ramp. You say that you are unable to leave your home without a
ramp. The Plan denied your request. The Plan says items that are not used to treat medical conditions, but
rather are for comfort and convenience are not benefits of the plan

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

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. Therefore, we
decided that the Plan does not have to pre-approve a scooter ramp (A9270).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 23, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage of all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. In this case, there are insufficient medical records from the ordering provider to show that the results of the testing would be used in the management of a specific medical problem. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on April 28, 2020.

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 denied code remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 (HCPCS
G0483) provided to the enrollee on April 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ultrasounds you received on December 3, 2020.

You asked the Plan to waive the co-payment. The Plan denied your request. The Plan says you are responsible for the cost share.

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 $105 co-payment for each Medicare-covered radiological diagnostic service.

Review of the file shows that received two ultrasounds on December 3, 2020. Per your contract with the Plan, there is a $105 co-payment for each ultrasound. However, the Medicare allowed amount for each of these services was $41.58 and $95. Given that the allowed amounts were less than the $105 co-payment, you have been asked to pay $41.58 and $95 for each of the ultrasounds, respectively. 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 ultrasounds you received on December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound repair (12032) provided on April 30, 2020.

You asked the Plan to pay for wound repair. You say that this code is supported. The Plan denied your request. The Plan says there is a more appropriate code for the service 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 12032 is repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm.

We find that CPT code 12032 is not supported in the medical record. Specifically, this code excludes hands, and the records show that the wound that was repaired was located on a finger.

Based on this information, we decided that Medicare rules for coverage of wound repair have not been met. Therefore, we decided that the Plan does not have to pay for wound repair (12032) provided on April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on August 4, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and the rules. We find that the testing is not supported. There are insufficient records to show the results would be used in the management of a specific medical problem. The file also shows that the ordering provider on the claim did not authorize or order the testing. 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 hereditary cardiovascular testing provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative treatment and is not interested in surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is considered investigational at this time.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show the safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).