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

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
6, 2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you had an annual 
wellness visit before and never received a copayment. 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 $15 
copayment per visit for laboratory tests. 
 
You have been asked to pay $13.39, which is less than the standard $15 copayment for the laboratory services. 
The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 
benefit category. Diagnostic tests are considered a separate service. 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 laboratory services provided on November 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac gene panel testing provided on August 26, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare 
denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 

We looked at the file and the rules. There is insufficient records to show that the ordered testing is diagnostic, 
prognostic; or clearly correlates any test result with given interventions. The testing was requested for 
screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the 
Plan does not have to pay for the cardiac gene panel testing provided on August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transports from residence to dialysis and physician office.

You asked the Plan to pay for the non-emergent ambulance transports. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private 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 did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transports have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transports from residence to dialysis and physician office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), and the unspecified preventive service (D1999).

You asked the Plan to pay for the consultation and unspecified preventive service. You say that when you signed up for this plan, you were told that services would be covered at, at least 50%. You also say that you understand that you have $1,000 for dental services. The Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered service either. The Plan says that the provider in this case is out of network. The Plan also says that out of network provider may be bill you for any amount greater than the payment made by the Plan to the provider.

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. Additionally, the out of network provider may be bill you for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay for the consultation (D9310), and the unspecified preventive service (D1999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs a LTACH admission. The Plan denied your request. The Plan says the services the enrollee needs could be provided in another setting.

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 patient appears to require additional short-term acute care services which can be safely administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available at the current facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the diagnosis is not appropriate.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documented diabetic foot disease.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit.

You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 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 a domiciliary, rest home visit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were not ordered/approved by the ordering provider.

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 documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services.

You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered for the indications established in the applicable LCD.

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 drug testing. Our reviewer says that the requested definitive drug testing services are not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 39-year-old male with a history of chronic pain. The record sent by his provider says that the enrollee has been in chronic pain since he had shoulder replacement surgery. He has been prescribed both long-acting morphine and short acting Oxycodone by the provider for his pain issues. Under Medicare guidelines, the request is not medically necessary because there is no clinical rationale to identify specific medications or illicit substances, beyond what was identified in the approved presumptive drug test. There were no positive inconsistent findings in the presumptive drug test. Thus, the definitive drug test is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit.

You asked the Plan to waive the copayment for the ER visit. You say that you did not receive any services and should not be responsible for the copayment. 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 each emergency room visit.

You have been asked to pay $82.94, which is less than the standard $100 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that laboratory services were provided during the ER visit. 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 ER visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission meets the CMS criteria. The Plan denied your request. The Plan says the requested LTACH services are not medically necessary, reasonable, or appropriate for the diagnosis and condition of the member at this time. The member can remain in the current acute care location until such time no further acute level care is needed.

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 that the enrollee is a 61-year-old male who was admitted to the acute care hospital with cellulitis of the left groin/left foot/left leg, septicemia, acute respiratory failure, acute renal failure, altered mental status, and gout requiring BiPAP, antibiotics, wound care, and fluids. The recent notes show improvement in the clinical status of the enrollee, but he requires additional antibiotics, basic wound care in addition to debridement. The enrollee appears to be improving but requires additional short-term acute care services which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when the treatment has completed.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT code 92015), and fitting of spectacles, except for aphakia; monofocal (92340) provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the vision services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider is out-of-network.

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 codes 92015 and 92340 was denied correctly since refractive and glasses are not covered if the services had rendered out-of-network as per EOC 90 and 91. The health plan contract says that in-network, the enrollee will pay $0 for routine eye exam, eye exam will include refraction and dilation. The enrollee will pay any amount over $300 for in-network purchase and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider (per calendar year). The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for determination of refractive state (CPT code 92015), and fitting of spectacles, except for aphakia; monofocal (92340) provided to the enrollee by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid flow or fluid gf 1 cc (Q4206) and lidocaine (J2001).

You asked the Plan to pre-approve Fluid flow or fluid gf 1 cc (Q4206) and lidocaine (J2001). You say that the requested Fluid flow or fluid gf 1 cc (Q4206) is medically necessary. The Plan denied your request. The Plan says the requested Fluid flow or fluid gf 1 cc (Q4206) is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Fluid flow or fluid gf 1 cc (Q4206) and lidocaine (J2001). Our reviewer says that the requested Fluid flow or fluid gf 1 cc (Q4206) is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain for the past 20 years. He is taking high dose opiates (over 200MME per day) for pain. He is also taking Ibuprofen for pain. There is no imaging submitted for review. The request is for Fluid flow ammonitic allograft. This is an experimental/investigational procedure for low back pain. Therefore, the request is considered not medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid flow or fluid gf 1 cc (Q4206) and lidocaine (J2001) have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid flow or fluid gf 1 cc (Q4206) and lidocaine (J2001).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs a LTACH admission. The Plan denied your request. The Plan says the enrollee can transfer to a lower level of care for rehabilitation or skilled services can be considered.

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 patient appears to be improving and requires additional short-term acute care services which can be safely administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available at the current facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, oral hygiene instructions, and bitewing x-rays.

You asked the Plan to pay for the intraoral periapical x-rays, oral hygiene instructions, and bitewing x-rays. You say that you assumed these services would be covered. The Plan denied your request. The Plan says intraoral periapical x-rays and oral hygiene instructions are not covered benefits. The Plan also says that your bitewing x-rays benefit had been satisfied and the frequency limitation had been exceeded.

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 first intraoral periapical x-ray, additional intraoral periapical x-ray, and oral hygiene instructions are not among those covered under this benefit. The Plan contract includes one set of bitewing x-rays per calendar year. The record shows that you received bitewing x-rays and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, oral hygiene instructions, and bitewing x-rays.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the requested item was medically reasonable. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).