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

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640, 87798, and U0004) provided to the enrollee on July 2, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 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 laboratory services. Our physician reviewer found there is no specific clinical rationale for the requested laboratory studies. The review has determined that the services were not supported by the medical records. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640, 87798, and U0004) provided to the enrollee on July 2, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on July 17, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that that billed
taxonomy code does not match the taxonomy code under the provider record.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the Plan has not provided a rule which clearly states that taxonomy
is a required field or that it must match the NPI's taxonomy. Without supporting documentation, the Plan's
denial cannot be substantiated. Please note, this is regarding the services which were billed on the claim with
Type of Bill (TOB) 0857. Therefore, we decided that the Plan has to pay for the lab services provided on July
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (S2900).

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says this CPT code is not covered.

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 S2900 is not supported in the medical record. Specifically, per the National Physician Free Schedule, this CPT code has a status of "I" which means it is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (S2900).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided on August 5, 2020.
You asked the Plan to pay for the lab services. You say that the lab testing was medically necessary. The Plan denied your request. The Plan says the service was not pre-authorized.
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 service 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 lab services (81455) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation and the prophylaxis received from an out-of-network (OON) provider.
You asked the Plan to waive the coinsurance for the dental services. You say that you used the same dentist you have used in the past and were not informed that the services would be considered out-of-network. The Plan denied your request. The Plan says services were provided by an OON provider and therefore the correct cost share applied to the claim.
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 Plan requires a 20% coinsurance for items or services received from an out-of-network provider. Therefore, we decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation and the prophylaxis received from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the muscle test provided on January 7,
2019.
You asked the Plan to waive the copayment for the muscle test. You say that you were never told there would
be a copayment and you do not feel like you should be responsible for this amount. The Plan denied your
request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copayment for all other covered diagnostic procedures and tests.
You have been asked to pay a $100 copayment for the muscle test. The muscle test falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The record shows the muscle test is
considered a non-radiological diagnostic test. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the muscle
test provided on January 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve median nerve block injections.
You asked the Plan to pre-approve the median nerve block injections. You say that you would like reconsideration because this service will help the member's pain and numbness. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the median nerve block injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested services are not covered for the management of this member's type of neuropathic discomfort. Therefore, this is not eligible for coverage at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the median nerve block injections have not been met. Therefore, we decided that the Plan does not have to pre-approve median nerve block injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code G0483) provided on March 6, 2020, by a non-participating provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee was self-referred to the non-participating provider for an office visit and medical records provided to the Plan do not reveal any medially urgent or emergent services. The Plan states the records indicated the enrollee was seen as a follow up visit due to head, neck and lower back pain. The Plan states the provider that performed these services is not within the Plan's network and the Plan had network providers available to perform the services.
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 had network providers available who could have provided 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 the laboratory services (CPT code G0483) provided on March 6, 2020, by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services (92012, 83516, 83516).

You asked the Plan to pay for the vision services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers 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 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 vision services (92012, 83516, 83516).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because all of the member's treating providers recommend SNF care because the member cannot be safely discharged home. The Plan denied your request. The Plan says it is not evident that the member needs the skills and judgement of a daily skilled nurse or therapist.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine Tab 25mg, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is needed for nausea. You state this medication is not being initiated within 2 hours of the administration of chemotherapy and continued for a period not to exceed 48 hours from that time and this medication is not going to be used as a full therapeutic replacement for intravenous (IV) anti-emetic therapy that would have been administered at the time of the cancer chemotherapy treatment. The Plan denied your request. The Plan says Promethazine is not being initiated within 2 hours of the administration of chemotherapy and continued for a period not to exceed 48 hours from that time and will be not used as a full therapeutic replacement for intravenous (IV) anti-emetic therapy that would have been administered at the time of the cancer chemotherapy treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medication have not been met. Medicare states that certain medicines may be covered under a beneficiary's medical benefit. The only medications that Medicare covers under the Part B benefit are certain oral anti-cancer drugs and anti-nausea drugs for treating chemotherapy-related nausea, medicines to prevent rejection of an organ transplant, and injectable medicines not usually taken by the member themselves. Medicare also says that the anti-nausea medicine must completely replace IV anti-nausea medicines. The requested medicine would be provided under the pharmacy benefit and is not covered under the medical benefit. The member does not have a Part D (pharmacy) benefit or a commercial pharmacy benefit with the Plan. Therefore, we decided that the Plan does not have to pre-approve Promethazine Tab 25mg, for the enrollee.
Benefits for the medication 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053, 80061, 82306, 82607, 83036, 84443, 85025) provided August 31, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the tests were provided as screening tests and 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 test at issue in this appeal, the lab services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The plan requested additional medical records to support the services and none were provided. Therefore, we decided that the Plan does not have to pay for lab services (80053, 80061, 82306, 82607, 83036, 84443, 85025) provided August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory testing 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 laboratory services provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi electric hospital bed.
You asked the Plan to pre-approve a semi electric hospital bed. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not clearly reveal your condition requires positioning of the bed in ways not feasible in an ordinary bed. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for you. 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 semi electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided from October 6, 2020, through October 23, 2020.
You asked the Plan to pay for the acupuncture services. You say that you did not know the provider was ineligible. The Plan denied your request. The Plan says per guidelines, acupuncture is covered for chronic low back pain only when performed by a medical provider. The Plan states that you called to verify coverage only and you did not call to verify whether or not this provider was participating or would be covered. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from October 6, 2020, through October 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech therapy.
You asked the Plan to pre-approve speech therapy. You say that the services are necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 speech therapy. 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 based on the medical records provided there is no documentation that
the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
Further therapy at this point does not appear to be likely to achieve any significant improvement in the
enrollee's symptoms or swallowing function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve speech therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on September 24, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient surgery services rendered by an out-of-network hospital or ambulatory surgical center. You have been asked to pay $3,420.40 (Plan allowed amount of $17,101.99 x 20% coinsurance) for the outpatient surgery rendered by an out-of-network 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 coinsurance for the outpatient surgery provided on September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an ear cartilage graft (21235-GZ) provided on October 14, 2020.
You asked the Plan to pay for an ear cartilage graft. You say that the medical records support this service. The Plan denied your request. The Plan says this is not payable with the GZ modifier.
The Plan must follow Medicare rules. Medicare rules say that claim line items submitted with a GZ modifier will be automatically denied. We looked at the file and Medicare rules. The service at issue was billed with the GZ modifier. Based on this information, we decided that Medicare rules for coverage of an ear cartilage graft have not been met. Therefore, we decided that the Plan does not have to pay for an ear cartilage graft (21235-GZ) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan provided on April 9, 2020.
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says non-emergent, 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 CT scan. 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 CT scan provided on April 9, 2020.