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

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on March 12, 2019.
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 services are 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 80156 is total carbamazepine assay. The definition of code 80157 is free carbamazepine assay. The definition of code 80159 is clozapine assay. The definition of code 80162 is total digoxin assay. The definition of code 80173 is haloperidol assay. The definition of code 80201 is topiramate assay. We find that CPT codes 80156, 80157, 80159, 80162, 80173, and 80201 are is not supported in the medical record. Specifically, the records do not contain documentation that a total carbamazepine assay, free carbamazepine assay, clozapine assay, total digoxin assay, haloperidol assay, and topiramate assay were performed.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation to support codes 80307 and G0483. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
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 laboratory services rendered to the enrollee on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 19, 2019.You asked the Plan to waive the copayment for the office visit. You say that you only had your annual wellness check which should be free. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $10 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that in addition to annual wellness visit, the claim shows diagnosis codes for an old myocardial infarction, mixed hyperlipidemia, other obesity, hypothyroidism, impaired fasting glucose, and essential primary hypertension. 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 forthe office visit provided on June 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 10, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4K score test provided to the enrollee on July 8, 2019.You asked the Plan to pay forthe test. You say that this was medically necessary based on the diagnosis to treat this enrollee.The Plan denied your request. The Plan says the 4Kscore test algorithm is considered not reasonable and necessary and is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules said that on the date of service at issue in this case, the 4K score test was not covered by Medicare Although this test currently has limited coverage, at the time of service, it was statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the test have not been met.Therefore, we decided that the Plan does not have to pay forthe 4K score test provided to the enrollee on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.You asked the Plan to pre-approvea Freestyle Libre Sensor. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Medicare guidelines say that in order for a therapeutic CGM to be covered, all criteria above must be met. Medicare covers therapeutic CGMs when the enrollee has been using a BGM and performing frequent (four or more times a day) testing and the enrollee is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. In this case, the file shows that you test your blood glucose levels less than four times per day and you take Trulicity once per week, which is not considered insulin. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Sensor have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the 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 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 forthe medical services provided to the enrollee by an out-of-network provider on August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips.You asked the Plan to pre-approve One Touch Ultra Blue test strips. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says they have approved a 3 month supply with no refills for the requested One Touch Ultra Blue test strips to help transition to a preferred brand covered by the Plan.The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations.We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide documentation from your treating physician that the requested non-preferred brand, One Touch Ultra Blue test strips are medically necessary. Based on this information, we decided that Medicare rules for coverage of One Touch Ultra Blue test strips have not been met.Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 8, 2018
to December 12, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services that this enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says clinically the
enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from December 8, 2018 to December 12,
2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services can be completed in a lower level of care, such as SNF.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, wound care, wound vacuum care, JP drain care, parenteral nutrition, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve additional months.You asked the Plan to pre-approve additional months.You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable anddiligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The case file does not show thatthe Plan made any attempts to obtain records from the Plan provider.Therefore, we decided that the Plan has to pre-approveadditional months.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93005) provided on August 16, 2019.You asked the Plan to pay for the electrocardiogram. You say that this service was medically necessary and rendered in good faith. The Plan denied your request. The Plan says code 93005 is identified as part of another procedure CPT/HCPCS code 93285 billed on the claim on the same day without an appropriate modifier.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 electrocardiogram has a bundled relationship with code 93285 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 electrocardiogram (93005) provided on August 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you are appealing based on medical necessity. 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 ordering practitioner 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 June 30, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on August 17, 2019.You asked the Plan to pay forthe chest x-ray. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided on August 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 11, 2019.
You asked the Plan to pay for the services. You say that the services were medically necessary and essential to the enrollee's care. The Plan denied your request. The Plan says this is not a covered test.
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 services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee was diagnosed with adenocarcinoma of the lung. Testing related to adenocarcinoma of the lung, the results of which may affect treatment (i.e. related therapies exist), would be considered medically necessary and reasonable. Panel testing, inclusive of tests not related to adenocarcinoma of the lung or which otherwise would not affect treatment (i.e. no related therapies exist) are not consider medically necessary or reasonable. No provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 lab services provided to the enrollee on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient clinic visits provided on September 25, 2019 and October 3, 2019.
You asked the Plan to waive the copayments for the outpatient clinic visits. You say that you were unaware of the charges for clinic visits when you renewed your plan. The Plan denied your request. The Plan says the copayments 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 all other Medicare- covered, in-network outpatient hospital services. You have been asked to pay a $20 copayment for each outpatient clinic visit. The total amount you owe is $40 ($20/visit x 2 visits - $40). The outpatient clinic visits fall within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the outpatient clinic visits provided on September 25, 2019 and October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forMTHFR gene analysis testing provided on August 30, 2019.You asked the Plan to pay forgenetic test. You say that the Plan has no basis to deny coverage for this test that is covered by Medicare.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare except for pregnant patients.The Plan must follow Medicare rules. Medicare rules say that MTHFR gene analysis testing is not covered by Medicare except for in pregnant patients. We looked at the file and Medicare rules. The record does not show that the enrollee was pregnant at the time this testing was performed. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met.Therefore, we decided that the Plan does not have to pay forMTHFR gene analysis testing provided on August 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 7, 2019.You asked the Plan to pay for the physician's services. 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 servicesat 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 physician's servicesprovidedon May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee by an out-of-network provider from July 31, 2019, to August 27, 2019.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says there is no network deficiency for 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 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 chiropractic services provided to the enrollee by an out-of-network provider from July 31, 2019, to August 27, 2019.