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

We decided that the Plan does not have to pay for acupuncture services (97811 and 97810) provided from
September 18, 2020, through October 2, 2020.
You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because
you were informed that the member had acupuncture coverage. The Plan denied your request. The Plan says
this service was rendered by a non-covered provider type.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, this service was not rendered by a physician licensed
to perform acupuncture. Therefore, we decided that the Plan does not have to pay for acupuncture services
(97811 and 97810) provided from September 18, 2020, through October 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 5, 2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on May 22, 2020.
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because no proof of delivery was provided for the billed item.
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for coverage of a lumbar-sacral orthosis. We looked at the file and Medicare rules. The documentation submitted does not include proof of delivery for the specific item billed on this claim. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction provided on October 21, 2020.
You asked the Plan to pay for refraction provided from a non-preferred provider. You say that this exam is a covered benefit. The Plan denied your request. The Plan says the services were not provided by a provider from the Plan's Provider Directory.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the preferred provider during a routine eye exam. We looked at the file and the Plan's rules. You did not have a routine eye exam and services were not provided by the preferred provider. Based on this information, we decided that the Plan's rules for coverage of refraction provided from a non-preferred provider have not been met. Therefore, we decided that the Plan does not have to pay for refraction provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (CPT code 01992) provided to the enrollee on September 16, 2020.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee underwent general anesthesia for lumbar epidural steroid injection on September 16, 2020. The Plan states there is no documentation of clinical or psychological circumstances that would necessitate the routine use of this clinical scenario.
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 service. Our physician reviewer found there was NO indication for general anesthesia and the American Society of Anesthesiology Committee on Pain has specifically stated that general anesthesia for epidural steroid injection is NOT generally indicated. Therefore, the anesthesia provided was NOT medically necessary or reasonable. 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 service have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (CPT code 01992) provided to the enrollee on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary for full recovery. The Plan denied your request. The Plan says IRF care is not medically necessary.
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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (CPT code G0283) provided to the enrollee on July 14, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 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 physician reviewer found documentation submitted was reviewed and DOES NOT MEET CRITERIA. Therapy visits do not include documentation that electrical stimulation on one or more areas was performed. Documentation has this service listed, however, no documentation of the service being performed, as well as the area or areas services were performed on. Therefore, this HCPCS code cannot be verified as performed. 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 electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (CPT code G0283) provided to the enrollee on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 5, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that this should be covered. The Plan denied your request. The Plan says the records do not support that the enrollee ever saw the order physician.
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 a lumbar-sacral orthosis (L0650) provided on September 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (CPT code D0274),
unspecified preventive procedure (D1999) and comprehensive oral evaluation - new or established patient
(D0150) provided on September 14, 2020.
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 the services are not covered for this date of
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. The records indicate the Plan has already issued reimbursement for a comprehensive oral
exam and bitewing x-rays for date of service January 28, 2020. This means you will not receive a
reimbursement for your claim cost. Additionally, we are unable to allow benefits for the unspecified preventive
procedure (D1999) because this service is not a covered benefit. However, the Plan states they paid a stipend to
participating providers to assist with the cost of personal protective equipment until September 30, 2020.
Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (CPT code
D0274), unspecified preventive procedure (D1999) and comprehensive oral evaluation - new or established
patient (D0150) provided on September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography with doppler complete for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee last medical notes provided in 9/20 record his status as stable without new symptoms of dyspnea or signs of LV dysfunction. He had an echocardiogram several months before that visit which showed normal LV function and his prior stress test in 2019 showed no ischemia and he was felt to be a reasonable cardiac risk for planned carotid surgery without further testing at that time. However, he has now recently been referred for repeat transthoracic echo with doppler. Based on the records provided there is no report of symptomatic change and no change in exercise tolerance, and his last echocardiogram was within less than one year (July 2020) with normal left ventricular function as noted in his preoperative assessment in September 2020. As such there is no clinical indication for repeat echocardiography currently documented in the records provided based on clinical guidelines and appropriate use criteria 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 pre-approve transthoracic echocardiography with doppler complete for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 9, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve cardiac stress testing with nuclear imaging for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says that the addition of imaging to standard treadmill testing is not the standard of care.
The Plan must follow Medicare rules. Medicare rules say that nuclear imaging is covered for assessment of the functional and prognostic importance of angina, chest pain, or angina equivalent symptoms and diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG/EKG changes occurring naturally or caused by drugs, bundle branch block, or left ventricular hypertrophy. 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 study. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has palpitations and chest symptoms and possibly ischemic T wave changes noted on Holter monitor at high heart rates and associated with chest symptoms. As such she will likely have these same non-specific, equivocal T changes on EKG stress testing and therefore concurrent nuclear imaging will almost certainly be required to provide some diagnostic specificity to these likely EKG changes during the high heart rates of exercise stress testing. This would be necessary to rule out cardiac ischemia. Based on this specific clinical situation, and the applicable CMS LCD rules (assessment of the functional and prognostic importance of angina, chest pain, or angina equivalent symptoms and diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG/EKG changes occurring naturally or caused by drugs, bundle branch block, or left ventricular hypertrophy), the enrollee meets the criteria for cardiac stress testing with nuclear imaging. 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 study have been met. Therefore, we decided that the Plan has to pre-approve cardiac stress testing with nuclear imaging for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on September 16, 2020.
You asked the Plan to pay for the 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. 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 documentation shows that a urine drug test was ordered. Those results were not sent to support the reasoning for this definitive drug test. The documentation does not support why 15-21 classes of drugs were requested. 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 for the drug testing coded G0482 provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the online fitness classes provided on December 2, 2020.
You asked the Plan to reimburse for the online fitness classes. You say that there are currently no in-person fitness classes in your area and want to be reimbursed for online exercise classes. The Plan denied your request. The Plan says the online fitness classes are not covered by your plan.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The online fitness classes are excluded from fitness reimbursement benefits. Therefore, we decided that the Plan does not have to reimburse for the online fitness classes provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for the unclassified drug injections (J3490) provided from April 14, 2020 to July 16, 2020.
You asked the Plan to waive or reduce the coinsurance for the drug injections. You say that you feel the coinsurance cost was calculated incorrectly. The Plan denied your request. The Plan says Medicare Part B drugs require 10% coinsurance. This claim was processed 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 10% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $106.93 on each date of service for the drug injections. The Plan's total approved amount (the total amount they allowed the provider to be paid) for these services on each date was $1,069.30. Medicare Part B prescription drug injections require 10% coinsurance ($1,069.30 x 10% = $106.93). 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 or reduce the coinsurance for the unclassified drug injections (J3490) provided from April 14, 2020 to July 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound rendered on August 17, 2020.
You asked the Plan to waive the copayment for these services. You say that you were told prior to the procedure that there would be no copayment. 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 $150 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
Review of the file shows that you received an ultrasound on August 17, 2020. Per the contract with the Plan, there is a $150 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $118.28. Given that the allowed amount was less than the $150 copayment, you have been asked to pay $118.28 for these services. The Plan cannot be held accountable for possible misinformation given by a provider regarding your cost sharing responsibility.
Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound rendered on August 17, 2020.