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

We decided that the Plan does not have to pay for the xT Tempus Gene Panel rendered on December 21, 2020.
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 were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary.
Our physician reviewer found the enrollee has a diagnosis of grade II follicular lymphoma of unspecified site, first diagnosed in 2012. He was treated with chemotherapy and now as recurrent and refractory follicular B-cell lymphoma. The documentation does not support that a 648 gene panel will directly impact the treatment or management of the enrollee in this case, and it has not been shown that the number of genes to be tested is reasonable and necessary to obtain necessary information for therapeutic decision making. The Tempus Gene Panel was therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the xT Tempus Gene Panel rendered on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on November 5, 2020.
You asked the Plan to waive the copayment for inpatient stay. You say that you were not admitted to the hospital and should not be obligated to this copayment. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $380 copayment per day for days 1 to 5 for inpatient stay. The record shows that you were admitted to the hospital as an inpatient during this stay, therefore the inpatient hospital copayment applies to this claim. This inpatient stay lasted 1 day, resulting in a copayment amount of $380. You have been asked to pay $380 copayment per day for days 1 to 5 for inpatient stay. inpatient stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show your acute condition necessitating hospitalization has improved and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services is not medically reasonable and necessary for the enrollee. It is not expected you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted but with chronic auditory and visual hallucinations. You did not show any abnormal behaviors or any symptoms which would require acute treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on May 28, 2020.
You asked the Plan to pay for the anesthesia services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 27, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 5, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were part of your annual physical and you thought that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 laboratory services. 

You received laboratory services on January 5, 2021. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment. 

You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit and to waive the copayment for the limited bilateral noninvasive physiologic studies received on October 20, 2020.
You asked the Plan to pay for the annual wellness visit and to waive the copayment for the limited bilateral noninvasive physiologic studies. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services received exceed your benefit limit. 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 $150 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a freestanding facility.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.
Review of the file shows that you have a $150 copayment requirement for outpatient diagnostic services. However, the allowed amount for the limited bilateral noninvasive physiologic studies is $113.72. Since this is less than your copayment requirement, you are being asked to pay the lesser amount.
You have been asked to pay a $113.72 for the limited bilateral noninvasive physiologic studies. The limited bilateral noninvasive physiologic studies fall within the outpatient diagnostic 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. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit and to waive the copayment for the limited bilateral noninvasive physiologic studies received on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy and related services provided on October 8, 2020.

You asked the Plan to pay for the cystourethroscopy and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the cystourethroscopy and related services are not supported in the medical record. Specifically, the Plan does not separately pay any provider or supplier other than the facility for services furnished to the enrollee in preparation for, or for a procedure or surgery. The enrollee received the services during or in preparation for a procedure or surgery at the facility. Payment for this service would be included in the facility Prospective Payment System (PPS) payment. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy and related services have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy and related services provided on October 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerumen removal rendered on July 7, 2020.
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 payable.
The Plan must follow Medicare rules. Medicare rules say that codes with a PC/TC indicator of 5 are not payable when provided in the outpatient hospital setting. We looked at the file and Medicare rules. Billed procedure code 69209 (removal of impacted cerumen) has a PC/TC indicator of 5 and the code was billed with POS code 22 for outpatient hospital. This code is not payable in this setting. Therefore, we decided that the Plan does not have to pay for the cerumen removal rendered on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued hemodialysis (HD) services to be provided by an out of network (OON) facility.
You asked the Plan to pre-approve the OON HD services. You say that it is felt that the enrollee should be allowed to continue with this OON provider indefinitely as the provider is attempting to become a network facility with the Plan. The Plan denied your request. The Plan says at this time, the HD facility remains OON. This facility is within the service area, and there are network HD facilities within the area which can provide the services the enrollee requires. A partial authorization for continued visits was approved in order to allow time for the enrollee to establish care at a network provider. Beyond this transition period, no further OON care will be approved.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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 dialysis services are not being provided while the enrollee is out of the service area. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve continued hemodialysis (HD) services to be provided by an out of network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and sacroilitis. Her physical exam lacks at least three separate SI joint tests; therefore, the records do not support that the requested SI joint injection is reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received January
13, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to get a new dentist and
she automatically performed the comprehensive oral exam. The Plan denied your request. The Plan says a
comprehensive oral exam is covered once every 36 months.

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 in
excess of those covered under this benefit. You are limited to one comprehensive oral evaluation every 36
months. You previously received a comprehensive oral evaluation on April 12, 2019. Therefore, we decided
that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit provided on November 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for clinic visit. You say that you are appealing with supporting records. 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 an 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 clinic visit provided on November 9, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the phenazopyridine, 95 mg, provided in an outpatient setting
on December 28, 2020.
You asked the Plan to pay for the self-administered drug. You say that you think this should be covered. The
Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
drug you received is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the phenazopyridine, 95 mg,
provided in an outpatient setting on December 28, 2020.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 11, 2020.

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 testing is not covered.

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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received June 8,
2020.

You asked the Plan to pay for the panoramic radiographic image. You say that you did not see this limitation in
your benefit manual. The Plan denied your request. The Plan says the requested service is only allowed once
every 36 months.

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 in
excess of those covered under this benefit. You had last received this service May 11, 2020. Therefore, we
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received June 8,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (CPT 95867) provided to the
enrollee on August 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 this was not reported 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 95867 is "Needle electromyography."
We asked our coding 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 supported by the submitted records. Our coding reviewer found the
procedure took place in the "On Campus-Outpatient Hospital" (POS 22). Therefore, the facility would report
TC (Technical Component), and the provider would report 26 (Professional Component) modifier, when the
provider utilizes equipment owned by a hospital/facility.
We looked at this coder'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 needle electromyography (CPT 95867) provided to the enrollee on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 27, 2020.
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 procedure code 99152 is 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 99152 is moderate sedation services by physician also
performing a procedure, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of
an independent trained observer to assist in monitoring the patient's level of consciousness and physiological
status, initial 15 minutes of service. 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 moderate
sedation services rendered on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on September 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 laboratory work provided on September 22, 2020 by an out of network (OON) provider.