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

We decided that the Plan does not have to waive the copayment for the screening mammogram you had with an
out-of-network provider on February 24, 2021.
You asked the Plan to waive the copayment for the screening mammogram. You say that this was a routine
mammogram that should be covered 100%. The Plan denied your request. The Plan says you were charged this
coinsurance 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 50%
coinsurance for breast cancer screenings you get from an out-of-network provider.
You have been asked to pay 50% coinsurance for the screening mammogram. You had this breast cancer
screening with an out-of-network provider. 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
screening mammogram you had with an out-of-network provider on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure, one or more areas, each 15
minutes (97110) provided January 6, 2021 to February 15, 2021.

You asked the Plan to pay for the chiropractic services. You say that you would like the non-covered services
to be covered by the plan. The Plan denied your request. The Plan says this service is not covered when
rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the therapeutic procedure, one or more areas, each 15 minutes (97110)
provided January 6, 2021 to February 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of gastrostomy or cecostomy services coded 49450 provided on February 9, 2021.

You asked the Plan to pay for the replacement of gastrostomy or cecostomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. In this case, we have confirmed that code 49450 for the replacement of gastrostomy or cecostomy services has a bundled relationship with code 76000 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 the replacement of gastrostomy or cecostomy services coded 49450 provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99233) provided December 28, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that the documentation does not support that this was an initial visit. Initial hospital care was paid for December 27, 2020. This was a follow up visit.
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 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient. We find that CPT code 99233 is supported in the medical record. Specifically, the plan denied the claim stating that initial hospital care was already paid for December 27, 2020 and an additional initial service could not be paid. The service at issue is CPT code 99233, Subsequent Hospital care. The records support that this service was in fact a follow up or subsequent service and not initial care. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have been met. Therefore, we decided that the Plan has to pay for subsequent hospital care (99233) provided December 28, 2020.
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: Imaging
Decision: Favorable

We decided that the Plan has to pay for radiology services (CPT 72146) provided to the enrollee on October 19, 2020.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 72146 remains not supported.

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 72146 is "magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material." 

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 supported by the medical records. Our physician reviewer found the enrollee was evaluated for mid-back pain and muscle weakness. The enrollee had MRI of the thoracic spine (CPT 72146) on 9/3/20 with appropriate reporting as well as documentation for symptoms. The exam should be approved for reimbursement. 

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 radiology services (CPT 72146) provided to the enrollee on October 19, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital clinic visit and laboratory services, provided on
January 25, 2021, by an OON provider.
You asked the Plan to pay for clinic visit and lab services. You say that you are asking for an appeal in this
matter. 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 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 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 a hospital clinic visit and laboratory services,
provided on January 25, 2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 15, 2020.

You asked the Plan to pay for therapeutic exercises. You say that this should be covered at the in-network rate.
The Plan denied your request. The Plan says this was not billed correctly.

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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this
service was provided in a home health setting. There is a more appropriate code for this service. Based on this
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met.

Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens upgrades (V2781, V2744) for your post-cataract-surgery eyeglasses purchased on September 15, 2020.
You asked the Plan to pay for the lens upgrades. You say that you have a $375 allowance for eyeglasses after cataract surgery, and you used your own frames for this pair of glasses. You feel that the upgrades should be covered. The Plan denied your request. The Plan says lens upgrades are excluded from Medicare coverage.
Medicare will cover one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL. Progressive lenses will be denied as non-covered. Tints may be covered in certain circumstances where it is medically necessary. The Plan follows Medicare rules. We looked at the file and the Plan's rules. Progressive lenses (V2781) are not covered by Medicare. Photochromatic tint (V2744) may be covered in circumstances where it is deemed medically necessary; however, both upgrades were billed with the GZ modifier which indicates that they were requested by the enrollee as a preference and not out of medical necessity. Photochromatic tint cannot be covered when it is billed with the GZ modifier and is indicated as not reasonable and medically necessary. Based on this information, we decided that Medicare's rules for coverage of the lens upgrades have not been met. Therefore, we decided that the Plan does not have to pay for lens upgrades (V2781, V2744) for your post-cataract-surgery eyeglasses purchased on September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 patient was admitted for supraventricular tachycardia, nausea, and vomiting. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 74-year-old male with chronic obstructive pulmonary disease who received physical therapy and occupational therapy in the acute hospital. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the eye exam (92014) and echo exam of eye thickness (76514) provided on March 2, 2021.
You asked the Plan to waive the copayments for the eye exams. You say that this was a routine eye exam appointment and should be covered in full. The Plan denied your request. The Plan says these copayments were 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 copayment for an eye exam to diagnose and treat diseases and conditions of the eye.
You have been asked to pay less than a $40 copayment for two eye exams. You say that this was a routine eye exam appointment. A routine eye exam is one that is provided to determine changes in vision for prescription eyewear. A routine screening is provided when there are no previous medical conditions are symptoms that require evaluation. The eye exams provided were billed with medical eye exam codes, not as routine exams or screenings, and were billed in conjunction with non-refractive, medical diagnoses. This means that the eye exams provided were diagnostic and/or medical rather than routine, and therefore these eye exams are considered eye exams to diagnose and treat diseases and conditions of the eye. 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 copayments for the eye exam (92014) and echo exam of eye thickness (76514) provided on March 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) home health physical therapy visits.

You asked the Plan to pre-approve five (5) home health physical therapy visits. You say that additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says ongoing skills of a physical therapist are not needed to provide treatment.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve five (5) home health physical therapy visits. Our reviewer says that additional home health physical therapy visits are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Based on the available records you appear to be poorly responsive to the therapist and to have minimal potential to improve with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 20,
2020.
You asked the Plan to pay for the services. You say that these tests are reasonable and necessary and covered
nationally when performed by a CLIA certified laboratory. The Plan denied your request. The Plan says
Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a
benefit.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found molecular genetic hereditary predictive screening testing is not a Medicare benefit for the diagnoses as
listed on the claim and are done for screening purposes.
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 pay for laboratory services provided to the enrollee on May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan.
You asked the Plan to pre-approve a duplex scan. 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 follows Medicare rules. Medicare rules say that non-invasive peripheral arterial vascular studies are covered under specific circumstances. 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 a duplex scan. Our reviewer says that the services are not medically necessary. Our physician reviewer found the most recent physical exam does not show examination of the lower extremities concerning peripheral pulses. There is no history of claudication or other red flag to mandate duplex scanning. Importantly, ankle brachial index (ABI) has not been done in order to assess the likelihood of lower extremity vascular insufficiency. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a duplex scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided February 23, 2021.
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says this test was ordered for screening purposes and was not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided February 23, 2021.