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

We decided that the Plan does not have to pay for genetic testing provided by provider on May 15, 2019.You asked the Plan to pay for genetic tests. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this testing was ordered by telemedicine which is a Medicare prohibited action.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for genetic testing provided by provider on May 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear medicine study 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 are no cardiac symptoms or abnormalities.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 the enrollee has increased coronary risk but no documented symptoms, cardiac exam abnormalities or electrocardiographic abnormalities concerning for ischemia. In this circumstance, coverage criteria for nuclear stress testing is not met since there are no documented covered indications for the procedure. Screening nuclear stress testing even in high risk patients has not been shown to improve cardiac outcome.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 notbeen met.Therefore, we decided that the Plan does not have to pre-approve a nuclear medicine study for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF care. You say that the enrollee needs to step down to a SNF level of care as she is not yet able to receive less than daily skilled services.The Plan denied your request. The Plan says that the enrollee can be treated by a nurse or therapist on a less than daily basis at this time.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that the documentation supports that the SNF admission is medically reasonable and necessary. Our physician reviewer found the member requires skilled nursing oversight of her medical conditions and medication management. She has cognitive impairment and would not be expected to be able to adjust medications or self-monitor her medical conditions. She is at high risk for secondary complications of immobility such as pressure ulcers and contractures. The member also requires skilled physical therapy services for mobility and occupational therapy for remainingactivities of daily living and adaptive equipment. The member's condition appears stable and she is slowly improving with the treatments being provided.The member requires both daily skilled therapy and nursing services. She is unable to perform essential activities of daily living such as bed mobility without assistance. The member's condition would be expected to deteriorate with services provided on a less than daily basis. The member had previously been able to function independently. Although she remains non-weight bearing for her right upper extremity her injury occurred nearly 3 months ago and a progression of her weight bearing status can be anticipated. She is not able to tolerate the intensity of acute level rehabilitation. SNF level care is themost appropriate level for this member.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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveadmission to a skilled nursing facility (SNF). 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 20, 2019 and billed under codes 80307 and G0483.You asked the Plan to pay for80307 and G0483. You say that this testing was medically necessary.The Plan denied your request. The Plan says Medicare billing criteria were not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on June 20, 2019 and billed under codes 80307 and G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided by provider on August 9, 2019.You asked the Plan to pay for medical nutrition therapy services. You say that your doctor thought it was important that you consult with a nutritionist due to your personal and family history of certain conditions.The Plan denied your request. The Plan says the denial of payment for this service is correct, because medical nutrition therapy is not covered by Medicare or the Plan under these circumstances.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided by provider on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 8, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on August 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic colonoscopy provided on September 16, 2019.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that you were told that you would not owe a copayment for a screening colonoscopy.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a diagnostic colonoscopy on September 16, 2019 due to a change in bowel habits. Therefore, the colonoscopy is not considered a screening and you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This costsharing 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 fora diagnostic colonoscopy provided on September16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for podiatry visit. You say that you are appealing with supporting documentation.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on October 4, 2019 by an out of network (OON)provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a gynecologic screening exam (99386) provided on May 13, 2019.
You asked the Plan to pay for a gynecologic screening exam. You say that you were not aware of the frequency limitations on this service. The Plan denied your request. The Plan says this service is covered only once a year.
The Plan must follow Medicare rules. Medicare rules say that a screening pap smear and related medically necessary services are covered if you have not had such a test during the preceding two years. The Plan contract states that if you are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past 3 years, a Pap test is covered every 12 months. We looked at the file and Medicare rules. The record shows that you previously had a gynecologic screening exam on January 8, 2019. This means that you have exceeded both the Medicare and Plan frequency limitation. Based on this information, we decided that Medicare rules for coverage of a gynecologic screening exam have not been met. Therefore, we decided that the Plan does not have to pay for a gynecologic screening exam (99386) provided on May 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 9, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not aware there would be a copayment. You say that the copayment should be removed. 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 $100 copayment for diagnostic radiology. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound 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 ultrasound provided on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to on November 15, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not benefits for the diagnoses listed on the claim.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 16, 2019.You asked the Plan to pay for lab tests. You say that the ordering physician wanted the enrollee tested under a medication monitoring profile, and you feel that this testing was medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora hepatitis A vaccine (90632) and administration (90632) provided on July 17, 2019.You asked the Plan to pay fora hepatitis A vaccine and administration. You say that you were not aware this was only covered under Part D. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide ahepatitis A vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a hepatitis A vaccine and administration.Therefore, we decided that the Plan does not have to pay fora hepatitis A vaccine (90632) and administration (90632) provided on July 17, 2019.Benefits for a hepatitis A vaccine and administration 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 drug testing services (80307 and G0482) provided to the enrollee on July 10, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing services (80307 and G0482) provided to the enrollee on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for cardiogenic shock. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee does not appear to have been amenable to weaning trials until recently. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a Chest X-ray (71045) provided September 10, 2019 by provider.You asked the Plan to pay for the X-ray. You say that services were correctly billed and medically necessary.The Plan denied your request. The Plan says that services were billed with the incorrect modifiers.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 71045 is supported in the medical record. Specifically, the use of the 26 and XE modifiers was appropriate. Based on this information, we decided that Medicare rules for coverage of the X-ray have been met.Therefore, we decided that the Plan has to pay fora Chest X-ray (71045) provided September 10, 2019 by provider.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 physician's services you provided on August 6, 2019 and August 23, 2019.You asked the Plan to pay for the physician's services. You say that you were not aware that you wereout-of-network with the enrollee's plan. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 servicesat 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 physician's services you provided on August 6, 2019 and August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone/APAP for the enrollee.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Hydrocodone/APAP for the enrollee.Benefits for this drug may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 30, 2019.
You asked the Plan to waive the copayment for the MRI. You sent in a copy of your bill. You say you are asking for help with this copayment. The Plan denied your request. The Plan says you have been charged 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 $175 copayment for diagnostic radiology other than CT scans. You have been asked to pay a $175 copayment for the MRI. The MRI 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 MRI provided on October 30, 2019.