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

We decided that the Plan does not have to pay for laboratory services (87150, 87651, 87481, 87491, 87500, 87511, 87529, 87591, 87640, 87641, 87653, 87661, 87798, 87801) provided on April 10, 2020.

You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 87651, 87481, 87491, 87500, 87511, 87529, 87591, 87640, 87641, 87653, 87661, 87798, 87801) provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says there is no peer reviewed evidence to support the medical necessity of this procedure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure and is the subject of on-going clinical trials. Therefore, the request is considered not 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 15, 2021 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on January 15, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair and seat lift mechanism for the enrollee.
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 documentation does not support that the enrollee is completely incapable of standing up from a regular chair, or completely incapable of ambulating.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided there is documentation that the patient has generalized osteoarthritis and neuropathy; details on hip joint involvement or neuromuscular disease are not provided. There is no documentation that a seat lift is included in the treating practitioner's course of treatment. Based on the medical records provided there is no documentation that a seat lift is likely to effect improvement in the enrollee's condition, or arrest or retard deterioration in the enrollee's condition. There is no documentation that the enrollee is completely incapable of standing from a chair in the home. The records state "hard to get up from chair at times." 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 a seat lift chair and seat lift mechanism for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the joint of the lower extremity (73721) provided on October 20, 2020.

You asked the Plan to waive the copayment for an MRI of the knee. You say that you believe you should have to pay 20% of the total allowed price which would be approximately $48. The Plan denied your request. The Plan says the correct copayment was applied.

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 $110 copayment for each Medicare-covered radiological diagnostic service, not including X-rays. 

You have been asked to pay a $110 copayment for an MRI of the knee. An MRI of the knee 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 an MRI scan of the joint of the lower extremity (73721) provided on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy for right leg varicosities.

You asked the Plan to pre-approve Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg (36471). You say that the enrollee has a bulging varicose vein over the ankle. The Plan denied your request. The Plan says several criteria are not met.

We looked at the file and Medicare rules. The record shows the vein is not greater than 4mm and there is no weight reduction or exercise plan. Based on this information, we decided that Medicare rules for coverage of Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg (36471) have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy for right leg varicosities.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of supportive documentation of pain relief.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found failure to achieve greater than 75% pain relief from the prior injection is a negative block. Negative blocks should not be repeated. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on June 30, 2020.

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.

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on June 30, 2020.
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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has breast cancer and underwent neoadjuvant chemotherapy followed by modified radical mastectomy with axillary node dissection yielding 1/12 positive nodes. The provided documentation does not indicate why the requested service does not exceed other available treatment modalities such as intensity modulated radiation therapy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower leg crutch substitute (E0118) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating the safety and effectiveness of this item.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no data provided showing that the lower leg platform/crutch substitute (E0118) is medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower leg crutch substitute (E0118) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on December 31, 2020.

You asked the Plan to waive the copayment for the CT scan. You say that you don't agree with the amount. The Plan denied your request. The Plan says the copayment 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 $200 copayment for CT, MRI, MRA, and SPECT scans. 

You have been asked to pay $153.07, which is less than the standard $200 copayment for the CT scan. The 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 the CT scan provided on December 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance transport provided on October 17, 2020.

You asked the Plan to waive the coinsurance for the ambulance transport. You say that you want the charges paid. 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). Your contract with the Plan clearly says that you must pay 15% coinsurance for each one-way Medicare-covered trip. 

You have been asked to pay $64.09, which is 15% of the allowed amount for the ambulance transport. The allowed amount is $427.29 (15% x $427.29 = $64.09). The ambulance transport falls within the "Ambulance 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 coinsurance for the ambulance transport provided on October 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive audiological evaluation
(92557) Tympanometry (92567) provided October 30, 2020.

You asked the Plan to waive the copayment for the audiology services. You say that your benefit description
indicates that there is no copay for routine hearing evaluation. However, you received a bill for a copay for the
hearing exam. The Plan denied your request. The Plan says the claim was processed, and the correct copayment
was applied per the Evidence of Coverage.

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 $40
copay for each Medicare covered hearing exam to determine if you need medical treatment for a hearing
condition.

You have been asked to pay $40 copay for the audiology services. The audiology services fall within the
Hearing 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 copayment for comprehensive
audiological evaluation (92557) Tympanometry (92567) provided October 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on September 18, 2020
You asked the Plan to pay for adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less (14060), and WOUND PREP F/N/HF/G Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children (15004). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the procedures are not supported by the medical 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 find that CPT codes 14060 and 15004 are not supported in the medical record. Specifically, the operative report did not include documentation of surgical preparation or of an adjacent tissue transfer. Based on this information, we decided that Medicare rules for coverage of adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less (14060), and WOUND PREP F/N/HF/G Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children (15004) have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided on September 18, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 services provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) for tooth # 7 provided on January 6, 2021.

You asked the Plan to pay for the dental service. You say that the dentist did this root canal without your permission. You say that no one from the dental office called to see if it was a covered benefit. You also say that you feel that this is not your fault and should not be responsible for the bill. The Plan denied your request. The Plan says the root canal is not listed as a covered service.

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 root canal (D3310) for tooth # 7 provided on January 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on December 21,
2020, by an OON provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for the
services rendered by an OON provider.

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 psychotherapy services (90834) provided on
December 21, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac genetic testing provided on September 24, 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 testing, 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. The records provided do not indicate the results of the testing would be used as part of a specific treatment strategy. The testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac genetic testing provided on September 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you still need additional treatment and medical care. The Plan denied your request. The Plan says you have no current skilled nursing needs and do not need skilled therapists to address generalized weakness.

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 SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist to contact guard assist level for functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.