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

We decided that the Plandoes not haveto pay fora vitamin assay panel received on January 7, 2019.You asked the Planto pay forthe testing. You say that this should have been covered.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that vitamin assay panels are not covered. The services at issue in this case are statutorily not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay fora vitamin assay panel received on January 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 2, 2020
under codes 81445, 81301, 88360, and 88342.
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 the criteria states that testing is indicated for diagnoses of Non-Small Cell Lung Cancer
(NSCLC) and metastatic Colorectal Cancer (mCRC). The clinical information submitted states that the enrollee
has a diagnosis of endometrial cancer. Therefore, Medicare criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Medicare has specific coverage criteria for this
testing. In this case, the diagnosis reported does not meet the criteria for the services billed. Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
genetic testing provided to the enrollee on June 2, 2020 under codes 81445, 81301, 88360, and 88342.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRA scan of the head (70544) performed on May 16, 2020.
You asked the Plan to waive the copayment for an MRA scan of the head. You say that you should not have to pay for a service you were told would be covered by your insurance. 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. In this case, the Plan is providing coverage for an MRA scan of the head. You have been asked to pay a $110 copayment for an MRA scan of the head. An MRA scan of the head 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 MRA scan of the head (70544) performed on May 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe three prefabricated post and cores in addition to crowns (D2954 x3), core buildup, including any pins when required (D2950), five retainer crowns (D6740 x5), and pontic (D6245) provided on May 21, 2020.You asked the Plan to pay forthe prefabricated post and cores, core buildup, retainer crowns, and pontic. 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 forthe three prefabricated post and cores in addition to crowns (D2954 x3), core buildup, including any pins when required (D2950), five retainer crowns (D6740 x5), and pontic (D6245) provided on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining balance for the alveoloplasty in conjunction with
extractions (D7311) for the lower right quadrant provided on July 28, 2020.

You asked the Plan to pay the remaining balance for the dental service. You say that the services you received
were due to an emergency. You say that you paid a total of $287 out of pocket for the services. You say that
you may have to pay additional costs. You also say that this was a lot of money as your income falls far below
the poverty line. The Plan denied your request. The Plan says that alveoloplasty in conjunction with extractions
is not 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 alveoloplasty in conjunction with
extractions is not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay the remaining balance for the alveoloplasty in conjunction with extractions (D7311) for the lower right
quadrant provided on July 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided on January 1, 2020, through June 29, 2020.You asked the Plan to pay forhome health services. You say that the services should be covered.The Plan denied your request. The Plan says no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that the provider at issue was not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's enrollment in Medicare for the date of service at issue.Therefore, we decided that the Plan does not have to pay forhome health services provided on January 1, 2020, through June 29, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug test with 15-21 classes (G0482) provided on January 28, 2020.
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says that the documentation shows that 8 drug classes were
tested.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia,
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed.
We find that CPT code G0482 is supported in the record. Specifically, the record clearly indicates that between
15 and 21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of
the drug test have been met. Therefore, we decided that the Plan has to pay for the drug test with 15-21 classes
(G0482) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 24, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on April 24, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on March 10, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that thePlan does not have to pay forthe drug testing services provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided  by an out of network (OON) provider.

You asked the Plan to pay for specialist 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. The Plan says that these services were self-referred.

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 specialist services provided by 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 a specialist visit provided on August 24, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because this was a pre-operative visit. 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 $50 copayment per visit with a specialist. You had a specialist visit on August 24, 2020. A pre-operative visit is subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty (PVP) procedure.

You asked the Plan to pre-approve the PVP procedure. You say that it is felt that this treatment would be helpful for the enrollee's symptoms. The Plan denied your request. The Plan says although the enrollee has failed conservative management, the CMS criteria are not met as the bone scan shows a chronic compression fracture at L1. The member has had pain for three years and does not have an acute or subacute fracture to support approval of the request.

The Plan follows Medicare rules. Medicare rules say that PVP can be covered by Medicare for the treatment of an acute or subacute compression fracture. 

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 PVP procedure. Our reviewer says that the requested procedure is not considered reasonable and necessary. Our physician reviewer found the criteria for vertebroplasty are not met. There is no evidence that the fracture is less than 6 weeks old. 

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 PVP procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous vertebroplasty (PVP) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from January 6, 2020, to August 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 medical services provided to the enrollee by an out-of-network provider from January 6, 2020, to August 3, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe cystourethroscopy (52235) provided on March 2, 2020.You asked the Plan to pay forthe cystourethroscopy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the documentation does not clearly indicate the actual date the service on which the procedure was performed; therefore, the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy have been met. Specifically, the record clearly indicates that the date of the procedure was March 2, 2020. The operational report and specimen collection date both support the billed date of service. Additionally, it is unclear if the note indicating a March 1, 2020 date of service is directly related to the billed procedure.Therefore, we decidedthat the Plan has to pay forthe cystourethroscopy (52235) provided on March 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says services in home health are duplicate and also not needed.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 in this case, the documentation doesn't support that you are home bound and are confined to the home. You have been participating in outpatient therapy.  Furthermore, the requested Home Health physical therapy would be a duplication of services. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.
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 home health services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional Home Health Skilled Nurse visits for this
certification period.
You asked the Plan to pre-approve 2 additional Skilled Nurse visits (G0299/G0300). You say that you need
additional skilled nursing visits. The Plan denied your request. The Plan says the documentation does not
support the medical necessity for more than the 3 approved skilled nursing visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 2 additional Skilled Nurse visits
(G0299/G0300). Our reviewer says that the service is not medically necessary. Our physician reviewer found
the enrollee does not require additional skilled nursing to effectively provide treatment, care, and/or services in
order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition
and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of
chronic medical problems or hospitalizations. The enrollee has been authorized to have 3 skilled nursing visits
for changing out the suprapubic catheter during the episode of care. The documentation doesn't support that the
member requires additional skilled nursing 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 2 additional Skilled Nurse visits (G0299/G0300) have not been met. Therefore,
we decided that the Plan does not have to pre-approve 2 additional Home Health Skilled Nurse visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833 and L2397) provided to the enrollee
on July 11, 2020.
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The
Plan says two or more diagnosis codes are mismatched.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that HCPCS codes L1833 and L2397 is not supported in the medical record. Specifically, it was not
appropriate to bill M17.11 for right knee and M16.12 for left knee when there is a more comprehensive
diagnosis code available to use. Based on this information, we decided that Medicare rules for coverage of the
item have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833
and L2397) provided to the enrollee on July 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on April 23, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this was a screening for urinary tract infection and is not covered by Medicare.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 appealwas 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 forlab services provided to the enrollee on April 23, 2020.