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

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on August 3, 2019.You asked thePlan to pay forthe drug testing. 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.We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records signed by the ordering physician stating exactly what tests are to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded 80307 and G0483 provided on August 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing panels provided on August 16, 2019.You asked the Planto pay forthe drug testing. You say that this is medically necessary testing which should be paid.The Plandenied your request. The Plansaysthere is no valid signed order for this testing.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. In this case, the order form is not signed and there isno record demonstrating the provider's intent for this testing to be performed.Therefore, we decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing panels provided on August 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient
rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 that the complexity of your nursing, medical, and rehabilitation needs do not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status
does not currently require intensive physician and nursing oversight only in an inpatient rehabilitation facility.
You may benefit from multiple therapies such as physical and occupational therapy but the documentation does
not support that your functional status requires an intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the Warfarin monitoring services provided on December 23, 2019 and December 30, 2019.
You asked the Plan to waive the copayments for the Warfarin monitoring services. You say that you have never been charged for this service from a different provider. You say you feel this is an error. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $18 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $18 copayment for the Warfarin monitoring services.
You have been asked to pay a $11.55 copayment for the Warfarin monitoring services on each date of service. The Warfarin monitoring services 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 copayments for the Warfarin monitoring services provided on December 23, 2019 and December 30, 2019.
Our decision is only about the December 23, 2019 and December 30, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to
the enrollee on March 10, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360? and NEXT-Generation?)
requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative
field
The Plan must follow Medicare rules. Medicare rules say that services must be coded correctly.
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDiclofenac Sodium Gel for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this drug is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pre-approveDiclofenac Sodium Gel for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe 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 drug testing services provided on July 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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 provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the above LCD 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 pre-approve the injection. Our reviewer says that the requested facet joint injection is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 62-year-old female with chronic pain syndrome, chronic neck pain, and chronic low back pain. She presented to pain management with neck and back pain. A CT scan of the lumbar spine shows multilevel discogenic disease, degenerative changes and mal-alignment with neural foraminal stenosis. There is no specific clinical rationale for the requested facet blocks. The requested facet joint injection is not medically reasonable or necessary according to the coverage criteria established in the above LCD. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is in no acute distress. She is receiving oxygen up to 3 liters. The enrollee does not have complex medical needs such as ventilator management/weaning, complex wound care, or an unstable cardiovascular condition. She is not receiving 3 or more IV medications and fluids. The documentation does not support that the enrollee requires more intensive services that an alternative level of care. Consequently, the requested LTACH services are/are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and periodontal scaling and root planning (D4341) provided on February 24, 2020.
You asked the Plan to pay for the dental services. You say that you asked the office staff not to perform any procedure that you would have to pay out of pocket for. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
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. Review of the file show that you received gingival irrigation - per quadrant (D4921) and periodontal scaling and root planning (D4341) on February 24, 2020. Gingival irrigation - per quadrant (D4921) is not listed in your EOC; therefore, it is not a covered. The cost share was applied correctly for periodontal scaling and root planning (D4341 x 2). You have a 50% coinsurance for the dental services. Therefore, we decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and periodontal scaling and root planning (D4341) provided on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by a participating provider on January 15, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that if the Plan truly believes in preventative medicine and early detection you will pay for this procedure. 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 an $80 copayment for outpatient diagnostic tests/diagnostic mammography/outpatient hospital. You have been asked to pay an $80 copayment for a diagnostic mammogram. Since the mammogram that was provided was diagnostic in nature, the correct copayment has been applied. A diagnostic mammogram falls within the outpatient diagnostic tests/diagnostic mammography/outpatient hospital 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 a diagnostic mammogram provided by a participating provider on January 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided to the enrollee by an out-of-network provider on March 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested therapy on March 12, 2020, is not generally accepted as specific and effective therapy for the enrollee's condition. There is no evidence of an updated treatment plan for this date of service. The enrollee had prior therapy but the documentation does not reveal that the enrollee had significant deficits, or evidence that prior therapy has led to significant objective functional improvement, or that she requires the unique skills of a professional therapist to safely and effectively provide treatment.
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 therapy services provided to the enrollee by an out-of-network provider on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on February 20, 2020.
You asked the Plan to waive the copayment for these services. You say that you should have no cost share. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered laboratory tests.
Review of the file shows that you received laboratory services on February 20, 2020. These services fall outside of the scope of an annual wellness visit. You have been asked to pay a $10 copayment for these services. These services fall within the Medicare-covered laboratory tests 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 laboratory services rendered on February 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric hospital services for the enrollee.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member's recovery may occur at a lower level of care.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 are not medically reasonable and necessary for the enrollee in this case. This enrollee does not appear to require inpatient mental health treatment as he is not a danger to himself or others and is cooperative and compliant. It does not appear that active treatment is taking place. It does not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that based upon review the records provided, the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient isnot shown to be a danger to himself or others,iswithout agitation or aggression without perceptual disturbance including auditory, visual hallucinations or delusions. We looked at this physician's review, the file, and Medicare rules. Basedon 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-approveinpatient psychiatric hospital services for the enrollee.
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 above.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on February 5, 2020.You asked the Plan to reduce the coinsurance for the Part B injection. You say that that the calculation on the Explanation of Benefits is incorrect and you are being overcharged $2.46.  The Plan denied your request. The Plan says you have been charged the correct cost sharing amount but that the Explanation of Benefits does not show the correct 'approved' rate for the service.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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $153.90 which is 20% coinsurance for the Part B injection. The allowed amount is $769.15. ($769.15 x 20%= $153.90). The Part B injection falls within the "Medicare Part B prescription drugs" 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 reduce the coinsurance for the Part B injection provided on February 5, 2020.Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits.