Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for tumor sequencing services provided to the enrollee on June 5, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says that chronic lymphocytic leukemia is not recognized as a condition where gene sequencing is considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that lab services are covered when they are medically necessary. 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 services. Our reviewer says that the services at issue in this case were medically reasonable and necessary. Our physician reviewer found the analysis provided by this assay/study will enhance therapy for this condition, and hopefully help the providers tailor therapy for this enrollee.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 been met.Therefore, we decided that the Plan has to pay for tumor sequencing services provided to the enrollee on June 5, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing identified by CPT code 81455. You asked the Plan to pre-approve genetic testing identified by CPT code 81455. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not covered. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.We looked at the file and Medicare rules. Medicare says that genetic testing submitted under CPT code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Based on this information, we decided that Medicare rules for coverage of genetic testing identified by CPT code 81455 have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing identified by CPT code 81455
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97530, and 97112) provided on August 20, 2019 to August 22, 2019. You asked the Plan to pay for physical therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 pay for physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no effectiveness to this therapy for a patient with a stroke that is more than 6 months' duration. A caregiver could have provided the same service to achieve the results. The services could be carried out by nonskilled personnel. The amount, frequency, and duration of the services are not reasonable under accepted standards of practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for physical therapy services (97110, 97530, and 97112) provided on August 20, 2019 to August 22, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy visits (97110, G0283) provided by the practice from July 15, 2019 to July 29, 2019.You asked the Plan to waive the copayment for physical therapy visits. You say that you were told your copayment for these services was $10.The Plan denied your request. The Plan says these services processed 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 $40 for outpatient rehabilitation services provided in an outpatient hospital. You have been asked to pay $40 for physical therapy visits provided by the practice. The practice is an outpatient hospital setting. 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 physical therapy visits (97110, G0283) provided by the practice from July 15, 2019 to July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99214) provided April 24, 2019 by the provider. You asked the Plan to pay for the physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the primary insurer must issue an explanation of benefits before the secondary insurer can process the claim.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the physician services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for physician services (99214) provided April 24, 2019 by the practitioner.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on July 18, 2019.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this service was medically necessary.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 2019 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 forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider from August 2, 2019 to October 21, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider from August 2, 2019 to October 21, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forexternal electrocardiographic (EKG) monitoring provided by the physician on April 25, 2019.You asked the Plan to waive the copayment forexternal EKG monitoring. You say that you paid a copayment of $25 in accordance with your plan's benefits, and should not be charged this additional copayment of $20.The Plan denied your request. The Plan says that the copayment amount you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $25 copayment for external EKG monitoring. This service is considered to be a component of a non-radiological diagnostic service, therefore the non-radiological diagnostic service copayment applies to this claim. The non-radiological diagnostic service copayment was already applied to this claim, therefore an additional copayment does not apply.The Plan says you must pay an additional $20 copayment for external EKG monitoring. Based on the Plan contract, however, you cannot be asked to pay more than the $25 copayment for external EKG monitoring which you have already been asked to pay.Therefore, we decided that the Plan has to waive the copayment forexternal electrocardiographic (EKG) monitoring provided by the physician on April 25, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the test strips, lancets, control solution, and batteries provided by the practice on August 5, 2019.
You asked the Plan to pay for the test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe test strips, lancets, control solution, and batteries provided by the practice on August 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110), manual therapy (97140), and electrical stimulation (G0283) provided on August 23, 2019 by out of network provider.You asked the Plan to pay for physical therapy services. You say that these are Medicare-covered services.The Plan denied your request. The Plan says these services were not authorized.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 therapeutic exercises (97110), manual therapy (97140), and electrical stimulation (G0283) provided on August 23, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 19, 2019 by out of network provider.You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and the Plan is required to cover testing at the Medicare payment rate.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan, the ordering physician is also out-of-network with the Plan, and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on March 19, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by out of network provider. You asked the Plan to pay for office services. You say that the enrollee was unaware she had this insurance at the time of service.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the rendering facility is also out-of-network with the Plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on February 22, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on February 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2019 by out of network provider. You asked the Plan to pay for office visit. You say that this doctor has treated you since 2011 and knows how to help you.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and you could have been treated within the Plan's 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 30, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation and management of a patient (99309) provided on January 2, 2019 by out of network provider.You asked the Plan to pay for subsequent nursing facility care. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has 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 for subsequent nursing facility care, per day, for the evaluation and management of a patient (99309) provided on January 2, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97530) provided on July 22, 2019.You asked the Plan to pay for physical therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.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 pay for physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, there is no indication prior physical therapy has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for physical therapy services (97530) provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the caloric vestibular test provided on March 21, 2019 billed with CPT code 92537.You asked the Plan to pay for the caloric vestibular testing. You say that the records support the billed services.The Plan denied your request. The Plan says there is no documentation of the code 92537.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 92537 is Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations).We find that CPT code 92537 is not supported in the medical record. Specifically, the report does not adequately describe the testing defined in this code. Based on this information, we decided that Medicare rules for coverage of the caloric vestibular testing have not been met.Therefore, we decided that the Plan does not have to pay for the caloric vestibular test provided on March 21, 2019 billed with CPT code 92537.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fexofenadine tab 180mg for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan saysthe requested medication is denied as a benefit exclusion.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Fexofenadine tab 180mg for the enrollee.