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

We decided that the Plan does not have to pay for the definitive drug testing provided on February 25, 2020.You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary testing and should be covered.The Plan denied your request. The Plan says the order form was not complete and does not indicate an order for the custom panel. The order does not indicate that the intent for the testing provided.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating physician. The documentation is not clear as to the intent of the ordering physician. Only one of two pages of the order form was submitted along with a form defining the provider's custom panel; however, the order does not indicate that the custom panel was requested.Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 77061) provided on January 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Procedure code 77061 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 77061) provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an electric hospital bed and a seat lift mechanism purchased on December 14, 2019 and January 4, 2020 from out-of-network providers.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says a hospital bed and lift chair mechanism, not the chair itself, are covered from an approved DME provider when the member meets criteria.
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 an electric hospital bed and a seat lift mechanism purchased on December 14, 2019 and January 4, 2020 from out-of-network providers.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the detection test by nucleic acid provided on February 18,
2020.
You asked the Plan to pay for the testing services. You say that you only perform this test in your hospital lab.
The Plan denied your request. The Plan says molecular genetic screening testing is excluded from coverage.
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 87631 is infectious agent detection by nucleic acid (DNA
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We find that CPT code 87631 is not supported in the medical record. 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. Based on this information,
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not
have to pay for the detection test by nucleic acid provided on February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex interspinous spacers 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 this is considered investigational and unproven.
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 device is experimental, and more research is needed.
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 Vertiflex interspinous spacers for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete denture -mandibular (D5120) and complete denture -maxillary (D5110) provided on January 29, 2020.You asked the Plan to pay for the dental services. You say that you should not be liable for the cost-share due to being informed you would receive reimbursement.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.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.Review of the file show that you received complete denture -mandibular (D5120) and complete denture -maxillary (D5110) provided on January 29, 2020. The plan processed the claim reimbursing the member $447.50 with member responsibility of $447.50. Your EOC states, you are responsible for 50% of billed charges up to the $2,000 allowance for covered preventative and comprehensive dental services provided by an Out of Network provider. You pay 100% of charges beyond your $2,000 allowance.Therefore, we decided that the Plan does not have to pay for complete denture -mandibular (D5120) and complete denture -maxillary (D5110) provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on August 19, 2019 by an outof-
network provider.
You asked the Plan to pay for the vision services. You say that you believed this provider was in-network. The
Plan denied your request. The Plan says you do not have out-of-network benefits.
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 vision services provided on August 19, 2019
by an out-of-network provider.
Your complaint about being told by your broker that this provider was in-network with your plan 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0297, 76376) provided on December 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must be between age 55-77 years. Medicare rules also say that CPT 76376 must be reported in conjunction with the base imaging procedure. We looked at the file and Medicare rules. The records show that the enrollee was not between the ages of 55-77 when the LDCT scan was provided. Additionally, CPT 76376 was not reported with the base imaging procedure code, which means that CPT 76376 is not payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (G0297, 76376) provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the viral RNA by PCR testing for 3-5 respiratory pathogens
provided on December 24, 2019.
You asked the Plan to pay for the viral RNA by PCR testing. You say that it is felt that this pathogen testing
should be covered. The Plan denied your request. The Plan says this is not a Medicare covered service.
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 pay for the viral RNA by PCR testing. Our reviewer
says that the lab testing at issue is not considered medically reasonable and necessary in this case. Our
physician reviewer found a nasopharyngeal swab was obtained for Influenza A, Influenza B, and RSV.
Laboratory results are in the case file. The listed diagnoses were Cough and Fever, unspecified. There are no
clinical records in the case file for review. Without clinical records, it cannot be determined whether the testing
by PCR for three respiratory viral pathogens was medically reasonable and necessary for the enrollee in this
case.
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 viral RNA by PCR testing have not been met. Therefore, we decided that
the Plan does not have to pay for the viral RNA by PCR testing for 3-5 respiratory pathogens provided on
December 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on April 19, 2019.
You asked the Plan to pay for the ambulance transport. You say that the ambulance service was medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee was conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. The enrollee was being transported back to the skilled nursing facility. Prior authorization was not requested. Based on this information, we decided that Medicare rules for coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on April 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99283) provided on January 12, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include medical records indicating that CPT code 99283 was distinct from CPT code 99284.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the emergency department services has a bundled relationship with code 99284 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99283) provided on January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 15, 2020.You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient office visit for the evaluation and
management of a new patient (99203) provided March 6, 2020.
You asked the Plan to waive the copayment for the outpatient office visit. You say that you made an
appointment for a diabetic eye exam. Now you received a bill and when you called to find out why you were
told that the provider billed for a medical exam. The Plan denied your request. The Plan says the cost share was
applied correctly per the plan benefits.
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 $50
copayment for each Medicare covered exam to diagnose and treat diseases or conditions of the eye.
You have been asked to pay $50 for the outpatient office visit. The outpatient office visit falls within the Vision
care 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 outpatient office visit for the
evaluation and management of a new patient (99203) provided March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from January 10, 2020, to March 2, 2020.You asked the Plan to pay for the services.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 you by an out-of-network provider from January 10, 2020, to March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a mammogram. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 a mammogram provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the brain (70553) provided February 1, 2020.
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.
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 70553 is not supported in the medical record. Specifically, the record shows the claim is a duplicate of a claim that has already been processed. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the brain (70553) provided February 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-intravenous conscious sedation provided on January 16, 2020.
You asked the Plan to pay for the non-intravenous conscious sedation. You say that this is needed for severe anxiety. The Plan denied your request. The Plan says that this is not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the non-intravenous conscious sedation provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit provided on December 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient clinic visit. 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.
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 outpatient clinic visit provided on December 12, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 6, 2019 to September 26, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP claim was not submitted. A RAP is required for services provided by nonparticipating home health agencies. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 6, 2019 to September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services received on November 16, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services received were not an emergency or urgent care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The laboratory services received were not emergent or urgent. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services received on November 16, 2019.