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

We decided that the Plan does not have to pay for a WATS3D CX brush biopsy provided to the enrollee on December 1, 2020.
You asked the Plan to pay for the services. You say that this should bde paid for. The Plan denied your request. The Plan says experimental and investigational 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 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 WATS3D CX brush biopsy was performed on the enrollee. His esophagogastroduodenoscopy (EGD) showed regular z-line, no esophagitis, hiatal hernia 1 centimeter without stricture. The standard is to use histology and cytology for biopsy in this clinical situation, and the WATS3D CX brush biopsy is not yet shown to lead to significantly improved outcomes overall compared to the current standard for this enrollee's condition according to the current literature. 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 a WATS3D CX brush biopsy provided to the enrollee on December 1, 2020.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing for a SNF stay. We decided that the Plan does not have to reduce the cost-sharing for a SNF stay to the amount you requested.
You asked the Plan to reduce the cost-sharing for a SNF stay. You say that you were not informed that you would owe anything for the services. The Plan says that the claims were processed correctly and you are being charged the correct amount. We decided that the Plan has to reduce the cost-sharing for a SNF stay from $890 to $712.
The Plan applied a copayment to the day you were discharged, however, you cannot be asked to pay a copayment for the day you are discharged. Therefore, we decided that the Plan has to reduce the cost-sharing for a SNF stay from $890 to $712.
We also decided that the Plan does not have to reduce the cost-sharing for a SNF stay to the amount you requested.
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 $0 copayment for days 1-20 and $178 copayment for days 21-100 for a SNF stay.
You had a SNF stay from December 7, 2020, to December 31, 2020. You are not being charged a copayment for days 1-20 (December 7, 2020, to December 26, 2020). You are responsible to pay a $178 copayment for days 21-24 (December 27, 2020, to December 30, 2020). $178 (copayment) x 4 (SNF days) = $712. Therefore, we decided that the Plan does not have to reduce the cost-sharing for a SNF stay to the amount you requested.
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 the services provided by an out-of-network provider on January 8, 2021.
You asked the Plan to pay for the 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 had network providers available who could have provided 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 services provided by an out-of-network provider on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and the additional periapical x-ray (D0230) provided on April 12, 2021.
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that limited oral evaluation is not listed as a covered service.
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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, the limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and the additional periapical x-ray (D0230) provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urine PCR panel testing (CPT code(s): 87482, 87798,
87799) provided to the enrollee on March 23, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the standard of care for the evaluation of urinary incontinence is urinalysis with
urine culture and sensitivity. The Plan states the PCR testing is considered unproven and not 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 laboratory services. Our physician
reviewer found the review indicates that the standard of care for the evaluation of urinary incontinence is
urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically
necessary. The medical records provided did not meet the requirements listed in the NCD for Medicare
coverage.
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 laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the Urine PCR panel testing (CPT code(s): 87482, 87798, 87799) provided to the
enrollee on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT, retrograde filling, and apicoectomy, provided to you on March 4, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services are not covered.
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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. The requested dental services are not listed, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for the cone beam CT, retrograde filling, and apicoectomy, provided to you on March 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on October 12 to December 7, 2020.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on October 12 to December 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 1, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this service was not available in-network. The Plan denied your request. The Plan says this service 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 May 1, 2020.
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 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee 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. There is not a reasonable expectation that this enrollee 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy; with biopsy (43239) provided on November 12, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $150 copayment for the Medicare-covered surgery provided at an ambulatory surgical center. 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 esophagogastroduodenoscopy; with biopsy (43239) provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on
March 16, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $40 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.
You have been asked to pay a $40 copayment for the Medicare-covered outpatient visit to diagnose and/or treat a condition 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 copayment for the office visit (99213) provided on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab work provided on March 9, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an ear mold insert (V5265) provided on March 15, 2021.
You asked the Plan to pay for the ear mold insert. You say that you do not understand what this service was or why it was billed this way. The Plan denied your request. The Plan says this service is not covered by your hearing benefit. The Plan also has already paid the full $750 allowance, and all other costs are your responsibility.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. An ear mold insert is not listed as a covered service under your routine hearing benefit. In addition, documentation shows that the Plan has paid the full $750 allowance for your hearing aid items. Based on this information, we decided that the Plan's rules for coverage of the ear mold insert have not been met. Therefore, we decided that the Plan does not have to pay for an ear mold insert (V5265) provided on March 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation services (A0425, A0427) provided on February 10, 2021.
You asked the Plan to waive the copayment for ambulance transportation services. You say that you are on a limited income and is wondering why you must pay so much. The Plan denied your request. The Plan says the copayment 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 a $290 copayment for each one-way ambulance transport received out-of-network.
You have been asked to pay a $290 copayment for ambulance transportation services. The EOC is clear that $290 is the required copayment for this service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency ambulance transportation services (A0425, A0427) provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 1, 2021.
You asked the Plan to pay for the testing services. You say that the testing will determine the enrollee's risk towards cardiovascular disease. The Plan denied your request. The Plan says Medicare denies all cardiovascular risk assessment testing, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing services were requested solely for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on January 1, 2021.
Sincerely,
Office of the Project Director Medicare Managed Care & PACE Reconsideration Project
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on October 9, 2020.
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 is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 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 the enrollee has regular urine drug screenings. There was one identified pain medication that the enrollee reported had been used for a recent tooth-pulling procedure. The test results match the history and did not require confirmation with definitive testing. Also, no other documentation supported definitive testing for any other reason. Therefore, the criteria for drug testing services (HCPCS G0483) was not met according to the provided documentation. 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 drug testing services (HCPCS G0483) provided to the enrollee on October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the computer assisted surgical navigation provided on November 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 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 that there was no need for computer navigation in this case. There was no clear advantage to computer surgery over conventional knee replacement. 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 the computer assisted surgical navigation provided on November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you have been to the hospital four (4) times in the past nine (9) months for the same condition and by approving SNF care it will improve your health. The Plan denied your request. The Plan says you do not have daily skilled nursing or therapist needs.
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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. However, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.