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

We decided that the Plan does not have to pay for Cyclophosphamide (J8530) provided from September 14, 2020, to October 11, 2020.
You asked the Plan to pay for Cyclophosphamide. You say that this is supported by the records. The Plan denied your request. The Plan says this was not billed with a required modifier.
The Plan must follow Medicare rules. Medicare rules say that if all of the requirements are met, the KX modifier must be added to the claim lines for the immunosuppressive drugs. If any of criteria have not been met, the GY modifier must be added to the claim lines. We looked at the file and Medicare rules. The drug at issue was not billed with either modifier KX or GY. Based on this information, we decided that Medicare rules for coverage of Cyclophosphamide have not been met. Therefore, we decided that the Plan does not have to pay for Cyclophosphamide (J8530) provided from September 14, 2020, to October 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85060) provided January 21, 2021.
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 claim was not billed with a valid place of service.
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 85060 is not supported in the medical record. Specifically, this CPT code has a professional component / technical component indicator of 8. Payment is only made for the professional component when the beneficiary is a hospital inpatient. The place of service billed was outpatient hospital campus (POS 22). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (85060) provided January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the transvaginal ultrasound (76830) provided on November 17, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 $160 copayment for each in-network Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).
You have been asked to pay a $102.01 copayment for the radiological diagnostic service provided. This is the Plan's allowed amount for this service which is less than the applicable copayment. 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 adjust the copayment for the transvaginal ultrasound (76830) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Fundus Photography (92250) provided on April 7, 2021.
You asked the Plan to pay for Fundus Photography. The Plan denied your request. The Plan says Fundus Photography is not a covered vision benefit.
Medicare does not cover Fundus Photography for routine screening. The contact with the Plan does not cover Fundus Photography.
We looked at the file, the Medicare rules and the Plan's rules. Medicare does not cover Fundus Photography for routine screening. The Plan's vision care benefit does not cover Fundus Photography. Therefore, we decided that the Plan does not have to pay for Fundus Photography (92250) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by a chiropractor from May 5,
2021, to May 27, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says the only chiropractic services covered by Medicare are manual
manipulation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for physical
therapy provided by a chiropractor from May 5, 2021, to May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nail trimming and routine foot care.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these services are not covered for a diagnosis of nail dystrophy.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. The records do not show that any of these conditions are present. The services you are asking the Plan to pre-approve are routine foot care services. 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 nail trimming and routine foot care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removals of torus mandibularis (D7473 x2) provided on April 21, 2021.
You asked the Plan to pay for the removals of torus mandibularis. You say that your dentist told you that he could shave your bone so that you would be able to get a proper fit. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 the two removals of torus mandibularis (D7473 x2) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic exam provided on September 28, 2020.
You asked the Plan to pay for the pelvic exam. You say that you changed doctors and had to have another exam. The Plan denied your request. The Plan says 2 pelvic exams within the 2020 calendar year are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pelvic exam have not been met. Therefore, we decided that the Plan does not have to pay for the pelvic exam provided on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81405, 81406, 81407, 81408, 81437, & 81479) provided October 30, 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 claim cannot be paid 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. 

We find that CPT codes 81404, 81405, 81406, 81407, 81408, 81437, & 81479 are not supported in the medical record. Specifically, Medicare rules state a genetic testing panel should be billed using CPT 81479. In this case multiple unbundled codes were billed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81405, 81406, 81407, 81408, 81437, & 81479) provided October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xF panel provided to the enrollee on February 10, 2021.

You asked the Plan to pay for the services. You say that the services The Plan denied your request. The Plan says the panel would be payable if billed as CPT 81479.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 the Tempus xF panel provided to the enrollee on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast prosthesis, mastectomy bra (L8000) purchased October 14, 2020.

You asked the Plan to pay for the mastectomy bra. You say that breast cancer survivors are entitled to replacement breast prosthesis every 2 years and you haven't had a replacement since 2016. You ordered on line and had it delivered and you request reimbursement. The Plan denied your request. The Plan says the supplier is not a Medicare certified supplier.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the breast prosthesis, mastectomy bra (L8000) purchased October 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits (97530).
You asked the Plan to pre-approve the additional physical therapy visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says 12 visits have already been approved. 12 additional visits (for a total of 24) exceeds the enrollee's needs.
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 the additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has pain with ambulation and decreased strength and range of motion in the right hip and knee. Records do not clarify why that the 12 physical therapy visits already approved by the health plan would be inadequate to treat the patient'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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits (97530).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on December 8, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. 

The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 81270, 82668, 86140, 85652)
rendered by the out-of-network (OON) provider on March 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 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 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 the laboratory services (36415, 81270, 82668, 86140, 85652) rendered by the out-of-network (OON) provider on March 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
December 19, 2020, through December 25, 2020.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the SNF services provided from December 19, 2020, through December 25, 2020 are denied due to no daily skilled need.
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 pay for continuation of SNF services provided from December 19, 2020, through December 25, 2020. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. long term care). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services provided from December 19, 2020, through December 25, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from December 19, 2020, through December 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen equipment rented for the months of February 20, 2021, to April 20, 2020.

You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you do not have any carry-on oxygen tanks in your possession. You say that you gave back the portable machine a long time ago. The Plan denied your request. The Plan says you were charged this coinsurance 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% coinsurance for durable medical equipment. 

You have been asked to pay 20% coinsurance for the oxygen equipment. We reached out to get additional records about your claim that you do not have a portable machine. Records show that in July of 2020, you were provided with a large portable oxygen cylinder that is kept at your home in case of a power failure. There is no evidence that you have ever returned this oxygen cylinder. Your oxygen provider is permitted to charge a monthly rental for this item even if you are not using it. If you wish to have this item removed from your home, you may contact the oxygen vendor to do so. 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 oxygen equipment rented for the months of February 20, 2021, to April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 14, 2021.

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 services are not covered.

The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary. 

We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on March 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed units exceeds the MUE value.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT codes 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2 units of each code, exceeding the MUE. 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 the services provided on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.
You asked the Plan to pre-approve Vyzulta. The Plan denied your request. The Plan says this drug it not
covered under your Part B plan.
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 pre-approve Vyzulta.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a discontinued esophagogastroduodenoscopy (43235-53) provided on March 29, 2021.
You asked the Plan to pre-approve a discontinued esophagogastroduodenoscopy. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct modifier.
The Plan must follow Medicare rules. Medicare rules say that modifier -53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services. We looked at the file and Medicare rules. The service at issue was billed as an outpatient hospital service, meaning modifier -53 is not appropriate. Based on this information, we decided that Medicare rules for coverage of a discontinued esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a discontinued esophagogastroduodenoscopy (43235-53) provided on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for complete ultrasound examination of the breast (76641, RT/LT) screening mammography (77067) February 10, 2021.

You asked the Plan to pay for the diagnostic services. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for process. The Plan denied your request. The Plan says the submitted documentation supports 1 unit each of 77067, 76641, and 76641, which were previously approved and paid on check dated March 23, 2021.

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, we find that CPT code 76641-26-RT, 77067-26 and 76641-26-LT is not supported in the medical record. Specifically, the submitted documentation supports 1 unit each of 77067, 76641, and 76641, which were previously approved and paid on check dated March 23, 2021. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for complete ultrasound examination of the breast (76641, RT/LT) screening mammography (77067) February 10, 2021.