Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on December 31, 2020, billed
with codes 36215-79-59 and 75710.
You asked the Plan to pay for the surgical services as billed. You say that these services were correctly billed.
The Plan denied your request. The Plan says the record does not support these two codes.
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 36415 is selective catheter placement, arterial system;
each first order thoracic or brachiocephalic branch, within a vascular family. The code definition of 75710 is
angiography, extremity, unilateral, radiological supervision and interpretation.
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the surgical services as billed. Our reviewer
says that the documentation does not support these codes as billed. Our coding reviewer found procedure report
does not give enough detail to confirm both CPT 36215 and CPT 75710 were performed. For CPT 36215
operative report states procedure was performed, however, does not document the details to confirm the
catheter was placed in the first order. Therefore, this procedure cannot be confirmed. For CPT 75710,
procedure report documents an image was taken, however, does not give details on the procedure performed to
confirm this service was performed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the
Plan does not have to pay for the surgical services provided on December 31, 2020, billed with codes 36215-
79-59 and 75710.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on February 19, 2021.
You asked the Plan to pay for the nursing facility visit. You say that the in-network nursing facility granted privileges to treat and provide medically necessary services. You say that the patient had no control over which physician would be assigned to their case and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was 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 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 nursing facility visit provided by an out-of-network provider on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 14) and the immediate lower
denture (D5140) provided on January 11, 2021.
You asked the Plan to pay for the dental services. You say that you called your insurance and told them that
you needed dentures because all of your teeth were going to be extracted. You say that a plan representative
advised that you could get insurance for that. You say that you believed that the plan you were paying for
covered dentures. You also say that you never received a policy booklet. The Plan denied your request. The
Plan says extractions are not listed as covered services. The Plan says that immediate lower denture is not listed
as a covered service either.
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 extraction and immediate lower
denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the extractions (D7140 x 14) and the immediate lower denture (D5140) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on January 26, 2021.
You asked the Plan to pay for the dental service. You say that your crown fell out while you were out of state. You say that you contacted the plan regarding a dentist while she was in California. You say that you were advised that you did not have coverage in California. You also say that since you were not able to get back to Utah, the plan representative gave you the information for the provider in this case. The Plan denied your request. The Plan says 2D oral or facial photographic image 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 2D oral or facial photographic image is not among those covered under this benefit. The Evidence of Coverage clearly states that any services
not listed are not covered. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on November 20, 2020.
You asked the Plan to pay for the testing services. You say that the lab test was provided in good faith. The Plan denied your request. The Plan says there was no specific reason for doing a definitive drug test.
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 G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. The records provided do not show that the test was individualized based on clinical history and risk assessment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided on November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for custom fitted foot brace (L1970, L2820, L2220), provided on December 16, 2020.
You asked the Plan to waive the coinsurance for custom fitted foot brace. You say that the coinsurance should be waived because you told the provider you did not want the cast in September and did not see the provider again, but the item was mailed to you anyway in December. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for durable medical equipment (DME) and supplies. You have been asked to pay a 20% coinsurance for custom fitted foot brace. custom fitted foot brace falls within the durable medical equipment (DME) and supplies benefit category. The records show that you were seen by the provider multiple times between September and December for fittings of this item and that you received the item in the providers office while there for a final fitting on December 16, 2020. 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 custom fitted foot brace (L1970, L2820, L2220), provided on December 16, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 18, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on November 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on January 30, 2021.
You asked the Plan to pay for the x-ray. You say that the enrollee was disenrolled from hospice prior to the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 29, 2021. The service in question was provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on January 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the step therapy criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 injection. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not support that Monovisc or Orthovisc have been tried and failed. There is no evidence that these drugs would be less effective and/or would likely have adverse effects for the enrollee in this case, as compared to Durolane. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens per lens (V2781), tint photochromatic lenses (V2744), and anti-reflective coating (V2750) provided February 10, 2021
You asked the Plan to pay for the routine eyewear. You say that you think the $300 should not be based on the retail cost. The Plan denied your request. The Plan says the allowance has been applied correctly to the retail price as stated in the EOC.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when up to a $300 allowance. You are responsible for any amount over $300 retail price. We looked at the file and the Plan's rules. In this case the Plan has correctly applied the $300 allowance toward your routine eyewear purchase. Therefore, we decided that the Plan does not have to pay for the progressive lens per lens (V2781), tint photochromatic lenses (V2744), and anti-reflective coating (V2750) provided February 10, 2021
Your complaint about the Plan's policy to apply the eyewear allowance to the retail price is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the office visit provided on February 24, 2021.
You asked the Plan to waive the copay for the office visit. You say that you were under the impression this was a family doctor. The Plan denied your request. The Plan says the claim was adjusted appropriately.
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 $5 copay for each in-person primary care visit.
You have been asked to pay a $5 copay for the office visit. The visit falls within the physician 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 copay for the office visit provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission.
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric admission. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health
treatment for the dates in question of June 22, 2021 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the advanced life support, emergency transport (A0427) provided on March 27, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee's hospice election did not occur until after the transportation services. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. The hospice benefit is effective for the date of service the election was made and is not time specific. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the advanced life support, emergency transport (A0427) provided on March 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) additional PT visits.
You asked the Plan to pre-approve seven (7) additional PT visits. You say that the additional PT visits are
medically necessary. The Plan denied your request. The Plan says the additional PT visits are not medically
necessary.
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 seven (7) additional PT 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 that the additional requested therapy is not generally
accepted as specific and effective therapy for your condition beyond what was approved by the health Plan.
You have had prior extensive therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a
therapist. You should be able to transition to an independent exercise program. The requested services are not
part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow
further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of seven (7) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve seven (7) additional PT visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from January 4, 2021, to January 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not urgent or emergent.
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 by an out-of-network provider from January 4, 2021, to January 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy services (97167) provided August 20, 2020.
You asked the Plan to pay for the outpatient therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code 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 code 97167 is not supported in the medical record. Specifically, the record shows the services were provided in the home setting. There is a more appropriate CPT code for this service (G0152).
Based on this information, we decided that Medicare rules for coverage of the outpatient therapy services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient therapy services (97167) provided August 20, 2020.
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 you were very independent before your surgery, and you need as much rehab as possible so you can return back to normal and go home. The Plan denied your request. The Plan says based on your current medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based on your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. The medical records do not support the ability to tolerate an intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per week.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.