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

We decided that the Plan does not have to pay for a cervical x-ray (72040) and a shoulder x-ray (73030)
provided on May 12, 2020.
You asked the Plan to pay for a cervical x-ray and a shoulder x-ray. You say that these codes are supported.
The Plan denied your request. The Plan says these codes cannot be verified.
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 72040 is radiologic examination, spine, cervical; 2 or 3
views and the definition of 73030 is radiologic examination, shoulder; complete, minimum of 2 views.
We find that CPT codes 72040 and 73030 are not supported in the medical record. Specifically, the submitted
medical records do not document the number of views taken of each of these x-rays. Based on this information,
we decided that Medicare rules for coverage of a cervical x-ray and a shoulder x-ray have not been met.
Therefore, we decided that the Plan does not have to pay for a cervical x-ray (72040) and a shoulder x-ray
(73030) provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services rendered on June 4, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 00790 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 00790 is anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified.We find that CPT code 00790 is not supported in the medical record. Specifically, there is no anesthesia report in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe anesthesia services rendered on June 4, 2020
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 September 16, 2020.
You asked the Plan to waive the copayment for lab work. You say that you do not agree 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 $20
copayment for outpatient diagnostic tests/laboratory tests.
You have been asked to pay $2.25 which is less than your copayment amount of $20 for lab work. Lab work
falls within the outpatient diagnostic tests/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 lab work provided by a participating provider on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe eyeglasses provided on September 6, 2020, by an out-of-network provider.You asked the Plan to reimburse you forthe eyeglasses. You say that you have used the same provider before and have never had any issues.The Plan denied your request. The Plan says you did not have prior authorization for the out of network eyeglasses.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you must get authorization for out of network services.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 itemsat issue in this appeal. The Plan did not pre-approve the itemsat issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to reimburse you forthe eyeglasses provided on September 6, 2020, by an out-of-network provide
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray provided on November 3, 2020 by an out of network (OON) provider.You asked the Plan to pay foran x-ray. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-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 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 foran x-ray provided on November 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (S9088) provided on November 3, 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 $50 copayment for each urgent care visit. You have been asked to pay a $50 copayment for the urgent care visit provided. 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 urgent care visit (S9088) provided on November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prometheus Anser testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is needed to determine the effectiveness of Stelara on the enrollee's condition. The Plan denied your request. The Plan says there is a lack of scientific evidence supporting the clinical utility of Prometheus Anser testing in general and even more so for Prometheus Anser UST testing in patients with Crohn's disease.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not yet been established pertinent to Stelara Anser testing whether the use of threshold drug levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. The available records do not support that the enrollee has lost response to Stelara, and thus does not meet the spirit of the AGA recommendidations, nor medical necessity criteria for the proposed Anser testing.

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Prometheus Anser testing for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound (76641) provided on September 4, 2020.
You asked the Plan to waive the deductible for an ultrasound. You say that this has been previously covered at no cost. The Plan denied your request. The Plan says this processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for medical services, including basic imaging services such as ultrasounds. The item or service you asked the Plan to waive the deductible for falls within the benefit category of basic imaging services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for medical services, including basic imaging services such as ultrasounds. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on September 4, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound (76641) provided on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transit Option (CPT Code K0108).
You asked the Plan to pre-approve the transit option. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the transit option is intended for use outside of the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve Transit Option (CPT Code K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from May 8, 2020 to May 31, 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 the dates of service do not match the number of units.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider billed 21 units for 23 day stay. The number of days the enrollee was in the facility should match the number of days for dates of service. Therefore, these services were reported incorrectly. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from May 8, 2020 to May 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve endovenous ablation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that Medicare holds that the treatment of a vein that is less than 5mm in diameter is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that varicose vein treatment can be covered if specific indications 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 therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation shows that the coverage criteria has been met. The documentation supports the medical necessity of the procedure in question. There is documentation of significant left lower extremity edema and efforts to treat conservatively. There is satisfactory documentation that the enrollee's symptoms are significantly impacting quality of life in that the enrollee has documented repeated episodes of cellulitis in that leg including recently. There is satisfactory documentation of severe reflux in the left greater saphenous vein and adequate arterial perfusion in that extremity. There is satisfactory classification data that meet criteria for coverage. Additionally, the treatment plan is focused on the area of concern and seems to be both reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have been met. Therefore, we decided that the Plan has to pre-approve endovenous ablation therapy 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for and the complete series x-ray (D0210) provided on
September 14, 2020.
You asked the Plan to pay for the complete series x-ray. You say that you understand that the full mouth x-ray
is not a covered service. You say that your policy does cover a set of bitewing x-rays once per year which you
have not had done. You say that bitewing x-rays are part of the full mouth series. You also say that the amount
that would be paid for bitewing x-rays should be applied to the complete series x-ray. The Plan denied your
request. The Plan says complete series x-ray 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, 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 and the
complete series x-ray (D0210) provided on September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires an interdisciplinary team, and
her needs cannot be met at a lesser level of care. The Plan denied your request. The Plan says it is unlikely that
the enrollee has the strength or tolerance for 3 hours of therapy a day.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for a COVID 19 infection and severe peripheral artery
disease requiring revascularization. Her medical conditions are stable. The complexity of her nursing, medical
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. There is not a reasonable expectation that she will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehab program.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that a lower level of care will not address the enrollee's
physical therapy or COPD issues. The Plan denied your request. The Plan says the enrollee's care is not
complex, and does not need a team of providers.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for a COPD exacerbation after recent femur fracture. Her
medical conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical
record documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program.
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 pay for the paring or cutting of a benign hyperkeratotic lesion
(11055) rendered by the out-of-network (OON) provider on August 20, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 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 the paring or cutting of a benign hyperkeratotic lesion (11055) rendered by the out-ofnetwork
(OON) provider on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on October 6, 2020.
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your
request. The Plan says an explanation of benefits from your primary insurance has not been submitted.
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 has directed this
claim to the primary insurance and has requested the explanation of benefits from the primary insurance. As the
secondary insurer, the Plan cannot be held responsible for an office visit until the primary insurer has denied
the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit (99214)
provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's care is
not complex, and he does not need a team of providers.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for a left below the knee amputation. His medical conditions
are stable. 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. While the medical record
documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program.
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.