Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided by the Department of Veterans Affairs (VA) from January 8, 2019, to December 5, 2019.

You asked the Plan to pay for services. You say that this is your bill for 2019 which you have paid in full. The Plan denied your request. The Plan says the denial of payment for these charges is correct, because the Plan is not the primary payer for these services received at the Department of Veterans Affairs.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. The rules also state that Medicare does not generally pay for services performed under authorization of the VA. 

You are requesting reimbursement for services performed by a VA provider. The Plan is not the primary payer for services performed by the VA and may not be responsible for any payment. An explanation of payment from the primary payer should be submitted to the Plan. Therefore, we decided that the Plan does not have to pay for services provided by the Department of Veterans Affairs (VA) from January 8, 2019, to December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit with an out-of-network provider on July 7, 2020, September 22, 2020, November 30, 2020, and December 29, 2020.

You asked the Plan to pay for the office visits. You say that you were told both providers are in-network. The Plan denied your request. The Plan says there were participating providers available and prior authorization was not received.

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 the office visit with an out-of-network provider on July 7, 2020, September 22, 2020, November 30, 2020, and December 29, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says that this is experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve the device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure (CHF), which appears very sensitive to volume-loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the Cardiomems device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. It would therefore meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule.

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 device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device for the enrollee.

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 psychotherapy provided on February 8, 2021 by an out of network provider.

You asked the Plan to pay for the psychotherapy (90837). You say that a disruption of service would be detrimental to the enrollee's mental health. The Plan denied your request. The Plan says you did not request prior authorization for the non-emergent 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on February 8, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on October 21, 2020.
You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on November 16, 2020.
You asked the Plan to pay for the moderate sedation 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 supported by the documentation.
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 provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99497) provided December 6, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records provided do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that the rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Insufficient medical records were submitted to support the claim. The plan made multiple requests for additional records. No additional documentation was provided. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99497) provided December 6, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for Gallium ga-68 provided on January 17, 2020.
You asked the Plan to pay for Gallium ga-68, dotatate, diagnostic, 0.1 millicurie (A9587). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the units billed exceed the allowed number of units in a day.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent 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. There is no claim, remittance, records, appeal letter, or screen print of the MUE information cited. The case file was requested by Maximus Federal Services and minimal documents were received. Therefore, we decided that the Plan has to pay for Gallium ga-68 provided on January 17, 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 waive the copayment for an office visit with a specialist (99214) provided on February 26, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you waited an hour in the providers patient room, for a fifteen-minute consultation. You also say that you do not think you should pay for a visit that did not provide you with new information. 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 $30 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $30 copayment for an office visit with a specialist. The EOC confirms $30 is the required copayment for this service. An office visit with a specialist falls within the physician/practitioner services, including doctor's office visits 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 office visit with a specialist (99214) provided on February 26, 2021.
Your complaint about the visit with the specialist is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on December 1, 2020.
You asked the Plan to waive the copayment for lab work. You say that you disagree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $5 copayment for outpatient diagnostic tests/lab. You have been asked to pay a $5 copayment for lab work. Lab work falls within the outpatient diagnostic tests/lab 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 lab work provided a participating provider on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinical breast examination provided on January 5, 2021.
You asked the Plan to pay for breast exam. You say that you did not realize you had to wait 2 years for this exam. The Plan denied your request. The Plan says the denial of payment for this service is correct, because a clinical breast exam is covered once every 2 years and you previously had one covered for date of service December 2, 2019.
The Plan must follow Medicare rules. Medicare rules say that a clinical breast exam is covered once every 2 years unless the enrollee is a woman of childbearing age or the treating physician recommends that she have the test performed more frequently based on evidence of high risk of developing cervical cancer. We looked at the file and Medicare rules. You previously had a covered clinical breast exam on date of service December 2, 2019, which was less than 2 years before this service. Based on this information, we decided that Medicare rules for coverage of breast exam have not been met. Therefore, we decided that the Plan does not have to pay for a clinical breast examination provided on January 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided on February 3, 2021.

You asked the Plan to pay for assistant at surgery services for the wrist endoscopy. You say that the surgical assistant assisted the primary surgeon and should receive compensation for ensuring the safety or the enrollee. The Plan denied your request. The Plan says Medicare guidance says procedures with a status indicator of 1 are not eligible for assistant at surgery reimbursement.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 29848. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for assistant at surgery services for the wrist endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided on February 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (23472) provided December 17, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation provided does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The plan made multiple request for additional documentation. Insufficient documentation was provided. There was no itemized record of the implanted items used in the procedure. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (23472) provided December 17, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for cardiac rehabilitation services (93798) provided on September 11,
2020, through September 25, 2020.

You asked the Plan to pay for the cardiac rehabilitation services. You say that you would like reconsideration
because the services rendered were medically necessary and integral to the member's treatment. The Plan
denied your request. The Plan says that the provider did not obtain authorization prior to rendering these
services.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent 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, the Plan has not forwarded a claim, explanation of benefits or
medical records to verify what was billed by the provider, if and why it was denied by the Plan and if the
services were urgent or emergent. It is the burden of the Health Plan to substantiate their denial with evidence.
In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided
that the Plan has to pay for cardiac rehabilitation services (93798) provided on September 11, 2020, through
September 25, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on November 6, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare
denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the
documentation in the beneficiary's medical documentation.

We looked at the file and the rules. We find that the testing services at issue are not supported in the medical
record. The records show that the Plan requested additional information on multiple occasions, with no success.
There are insufficient records to corroborate the billed services. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the testing services provided on November 6, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 27, 2020.
You asked the Plan to pay for genetic testing. You say that this test is covered by Medicare, and is only performed in your laboratory. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is not certified by the College of American Pathologists.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on October 27, 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 waive the copayment for an office visit with a specialist (99215) provided on January 5, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you had a visit with a provider as part of your preoperative care for a same day procedure. You also say that the office visit should be covered as part of the procedure. 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 $40 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $40 copayment for an office visit with a specialist. The EOC confirms that $40 is the required copayment for an office visit with a specialist. The EOC also confirms that $40 is the required copayment for medically necessary medical care or surgery services furnished in a physician's office including a specialist's office. 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 office visit with a specialist (99215) provided on January 5, 2021.