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

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on April 11, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation does not support the billed code.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 G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed".We find that CPT code G0482 is not supported in the medical record. Specifically, the records provided do not show that 15-21 drug classes were tested on the date of service in question. 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 drug testing services (G0482) provided on April 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient rehabilitation facility (IRF) care to be provided by an out of network (OON) provider. You asked the Plan to pre-approve OON IRF care. You say that the OON facility has programs that other facilities do not have. The Plan denied your request. The Plan says the requested services are available in-network.
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. 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 the inpatient rehabilitation facility (IRF) care to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the protective restoration sedative filling provided on February 25, 2020.
You asked the Plan to pay for the protective restoration sedative filling. You say that you were not told this would not be covered. The Plan denied your request. The Plan says that this is not 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the protective restoration sedative filling provided on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on March 9, 2020.
You asked the Plan to pay for the testing services. You say that you only perform this test in the hospital lab.
The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for
the diagnoses listed on the claim.
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 87631 is infectious agent detection by nucleic acid (DNA
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We find that CPT code 87631 is not supported in the medical records. In this case, there were insufficient
records provided to show the results of this testing would be used to determine a specific diagnosis or
determine a specific treatment strategy for a respiratory virus present in the enrollee at the time of service. This
testing is not covered for screening purposes. Based on this information, we decided that Medicare rules for
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for
the lab testing provided on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you are an insulin dependent diabetic and on the date of service your blood glucose levels dropped. You say that in your rush you became partially unconscious and you fell. Your spouse was unable to revive you so she called 911 for emergency assistance. The responding paramedics were able to revive you and treat you for injuries sustained in your fall. You say that once your glucose levels were stable you were able to communicate with the paramedics. You stated that they asked you if you wanted transport to the emergency room and you declined. You say that you consulted your treating physicians and decided that it was unnecessary to go to the hospital. You say that you believe your actions reduced the cost for the Plan and also did not tie up emergency resources that could be needed elsewhere. You asked the Plan to reconsider their denial and issue payment to the ambulance company. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 30, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided on March 3, 2020.
You asked the Plan to waive the copayments for X-rays. You say that you state that you should not be charged two separate copayments. The Plan denied your request. The Plan says the claims were processed correctly and you are being charge 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 X-rays. You have been asked to pay a $10 copayment for X-rays. X-rays 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 copayments for X-rays provided on March 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of test materials and equipment for home INR monitoring (G0249) provided on January 30, 2020 through February 12, 2020.
You asked the Plan to pay for the test materials. You say that this was billed in accordance with Medicare guidelines with one code being bill per week, for each time the enrollee tests. The Plan denied your request. The Plan says this code has a frequency limitation of no more than one unit per 25 days which has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the correct code to describe the services rendered. The rules also say that testing with the home PT/INR system should not be done more than once per week. In this case, the definition of the code G0249 is Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test materials have not been met. Therefore, we decided that the Plan does not have to pay for the provision of test materials and equipment for home INR monitoring (G0249) provided on January 30, 2020 through February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had on February 21,
2020.
You asked the Plan to waive the copayment. You say that this was ordered by your doctor. The Plan denied
your request. The Plan says you are responsible for the copayment.
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 $50
copayment for each specialist visit.
Review of the file shows that you had a specialist visit on February 21, 2020. You have been asked to pay a
$50 copayment for the visit. The visit falls within the physician 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 copayment for the office visit you had on February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide hearing aid services provided on December 13, 2019.
You asked the Plan to provide hearing aid services. You say that the services should be covered because they
are working to get the insurance resolved. The Plan denied your request. The Plan says they cannot correctly
pay the claim until the other insurance Explanation of Benefits is received.
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. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan cannot correctly
pay the claim until the other insurance Explanation of Benefits is received. As the secondary insurer, the Plan
cannot be held responsible for hearing aid services until the primary insurer has denied the claim for these
services. Therefore, we decided that the Plan does not have to provide hearing aid services provided on
December 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you fell and had cut your forehead. You say that shortly after you became light headed and were unable to communicate. Your spouse called 911 and the responders came and checked your vitals. You stated that you had begun to calm down and the responders said that it was probably an anxiety or panic attack. You say that thankfully you did not have to go to the hospital. You asked the Plan to reconsider paying for the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the outpatient visit. You say that you would like reconsideration because the out-of-network provider is qualified to treat the member's complex condition.The Plan denied your request. The Plan says the evaluation and treatment for the member's condition may be obtained from an in-network provider.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. 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on December 11, 2019.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) provided on October 9, 2019.
You asked the Plan to pay for the knee orthosis. You say that you would like reconsideration because the knee orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) provided on October 9, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study.
You asked the Plan to pre-approve a sleep study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that the requested sleep study is medically reasonable and necessary. Our physician reviewer found that while it is noted that you have a prior diagnosis of Obstructive sleep apnea (OSA) (From 2008), your sleep disordered breathing is not currently being treated. Your medical history includes conditions (CHF NYHA class III, pulmonary hypertension) for which would necessitate performance of a titration study (CPT 95811) in the attended setting. Given the desire to re-initiate you on a therapy for her sleep disordered breathing, the performance of an attended sleep study would be reasonable and necessary and consistent with the indications for which sleep testing is covered per the LCD. Our reviewer also notes that while the request was made for a split-night polysomnography, that shares the same CPT code as a titration study-CPT 95811, so this recommendation is for approval of CPT 95811 in general. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sleep study have been met. Therefore, we decided that the Plan has to pre-approve a sleep study.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 31, 2019.
You asked the Plan to pay for the services provided. You say that the services were billed correctly. The Plan
denied your request. The Plan says the tests are not Medicare benefits for the diagnoses listed on the claim.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the services provided, was requested for screening purposes. Medicare does not
cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 10, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit. 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 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 a hospital outpatient clinic visit provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ablation therapy (36482) to be provided by an out of network (OON) provider. You asked the Plan to pre-approve OON ablation therapy. You say that you have an office at the facility where the enrollee resides and these services are medically necessary. The Plan denied your request. The Plan says these services are available from in-network providers. 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. 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 the ablation therapy (36482) to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for transportation services provided on December 18, 2019.
You asked the Plan to reimburse you for the transportation services. You say that the transportation service was required in order to get the surgery. The Plan denied your request. The Plan says you received transportation services deemed not medically necessary by Medicare and the Plan's standards.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. You do not have a Routine Transportation benefit. Based on this information, we decided that the Medicare rules for coverage of the transportation services have not been met. Therefore, we decided that the Plan does not have to reimburse you for transportation services provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite -four or more surfaces, posterior (D2394) and periodontal scaling and root planing -four or more teeth per quadrant (D4341 x 2) provided on October 4, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says your plan was terminated before the services were rendered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your plan terminated September 30, 2019 and you had no active coverage at the time services were rendered.Therefore, we decided that the Plan does not have to pay for resin-based composite -four or more surfaces, posterior (D2394) and periodontal scaling and root planing -four or more teeth per quadrant (D4341 x 2) provided on October 4, 2019.