Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from August 19, 2020, through August 31, 2020.
You asked the Plan to pay for the inpatient admission. 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 an inpatient admission provided from August 19, 2020, through August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory assist device (E0470) provided on September 25, 2020, by an OON provider.
You asked the Plan to pay for a respiratory assist device. You say that the requested item was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a respiratory assist device (E0470) provided on September 25, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup.
You asked the Plan to pre-approve a battery backup. You say that the item is necessary. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a battery backup.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on January 21, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an x-ray on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $35 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an x-ray on January 21, 2021. You have been asked to pay a $35 copayment for the x-ray. The x-ray falls within the Outpatient diagnostic 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 x-ray provided on January 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health physical therapy services described by current procedural terminology (CPT) code 97110 provided on July 8, 2020.

You asked the Plan to pay for CPT code 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the medical records show that the services were performed by a physical therapist assistant in a home health setting. There is a more appropriate code that should be used to bill for the service provided. Based on this information, we decided that Medicare rules for coverage of CPT code 97110 have not been met. Therefore, we decided that the Plan does not have to pay for the home health physical therapy services described by current procedural terminology (CPT) code 97110 provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on November 3, 2020.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the eyeglasses were not provided by a participating vision provider with your Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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 a network optical provider. We looked at the file and the Plan's rules. The eyeglasses were not provided by the Plan's network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections at the C2-C3 level (64490, 64491, 64992).
You asked the Plan to pre-approve the facet joint injections. You say that facet joint injections are medically necessary for the enrollee. The Plan denied your request. The Plan says your request has been denied as this treatment is considered experimental.
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 facet joint injections. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee has chronic right sided axial neck pain. She has tried Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ice, heat, a home exercise program, and massage therapy. The facet joint injections are not medically reasonable and necessary for the enrollee. 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint injections at the C2-C3 level (64490, 64491, 64992).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided December 28, 2020.
You asked the Plan to pay for the chest x-ray. You say that the x-ray was medically necessary. The Plan denied your request. The Plan says this code is not eligible for separate payment.
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, we have confirmed that code 71045 has a column I / column II relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology testing provided on October 27, 2020.
You asked the Plan to pay for the molecular pathology testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that all services billed to Medicare must be reasonable and necessary. Medicare rules say that a physician order is not required to be signed, however, 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 file does not contain any medical records from the ordering/treating physician to establish medical necessity for the labs billed. We find that payment for the lab
services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the molecular pathology testing provided on October 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the patient would be equally well served at an alternative level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test described by current procedural terminology (CPT) codes G0483 and 80307 provided on September 14, 2020.
You asked the Plan to pay for CPT codes G0483. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT codes G0483 and 80307 have not been met. Therefore, we decided that the Plan does not have to pay for the drug test described by current procedural terminology (CPT) codes G0483 and 80307 provided on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on October 19, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 77067 and 77063 are not covered.
The Plan must follow Medicare rules. The plan must follow Medicare rules. The rules say that anatomical
modifiers are required for procedures performed on different anatomical sites. The rules say that providers
must report services correctly. Providers must report services with the appropriate CPT code.
We looked at the file and Medicare rules. Procedure code 77067 (bilateral screening mammography) was billed
with modifier -RT. This code is a bilateral code and cannot be billed with a lateral anatomical modifier. Code
77063 is an add-on code. Given that the primary procedure code 77067 is not covered, add-on code 77063 is
also not covered. Therefore, we decided that the Plan does not have to pay for the imaging services rendered on
October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services requested can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on December 8, 2020 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 water chamber for humidifier used with positive airway pressure device (A7046) provided on March 2, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the water chamber for humidifier used with positive airway pressure device. You say that the services provided were medically necessary. The Plan denied your request. The Plan says non-emergent services rendered by non-participating 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the water chamber for humidifier used with positive airway pressure device (A7046) provided on March 2, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on September 15, 2020.
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 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 code 81479. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 28, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the anesthesia services were provided to the enrollee while the enrollee was inpatient. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on December 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from January 6, 2021, through February 1, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the member must receive care from a network provider. In most cases, care received from an out-of-network provider will not be covered. 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 physical therapy services. 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 physical therapy services provided from
January 6, 2021, through February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on October 30, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician because the results were needed to help determine the course of treatment. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service October 30, 2020. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on August 3, 2020 by an out of network (OON) provider.