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

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on November 3, 2020.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are
non-covered.
We looked at the file and Medicare rules. The testing at issue is non-covered. Based on this information, we
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that
the Plan does not have to pay for CxBladder testing (0012M) provided on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3020) purchased on
December 21, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit under
your contractual policy or by Medicare for your condition.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics
(L3020) purchased on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the tendon sheath incision provided on January 8, 2021.
You asked the Plan to reduce the cost for the tendon sheath incision. You say that the surgery was scheduled in December but it was rescheduled. You say that the 2020 deductible that was met should be applied and you should only charged the copayment. The Plan denied your request. The Plan says the cost share applied 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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Your contract with the Plan says that you must pay a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The item or service you asked the Plan to reduce the cost for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract your $750 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the tendon sheath incision was received on January 8, 2021. Therefore, the Plan does not have to waive the deductible for the injection.
Since the $750 deductible was met, you have also been asked to pay a $125 copayment for the tendon sheath incision. 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 cost for the tendon sheath incision provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on October 19, 2020.

You asked the Plan to pay for the resin-based composite. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings and four gingival irrigations provided on November 18, 2020.

You asked the Plan to pay for the scalings and planings and gingival irrigations. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four periodontal scalings and root planings and four gingival irrigations provided on November 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 fractions IGRT, for the enrollee.
You asked the Plan to pre-approve the IGRT. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's records show that they have a problem (condition) or disease that is known to respond well to radiation therapy (RT). The Plan states the reason this request for daily picture studies cannot be approved is because only weekly picture studies are needed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IGRT have not been met. No clinical information was provided to verify if the services meet Medicare criteria. Therefore, we decided that the Plan does not have to pre-approve 10 fractions IGRT, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 16, 2020 and October 23, 2020.

You asked the Plan to waive the copayment for the urgent care visits. You say that your primary care physician wasn't seeing patients,so you had to go to urgent care. You say that you would have only been charged $10 if you saw your primary care physician.The Plan denied your request. The Plan says the copayment 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 $45 for each covered office visit to other providers for urgently needed services.

You have been asked to pay a $45 copayment for each urgent care visit. The total amount you owe is $90 ($45/visit x 2 visits = $90). The urgent care visits fall within the "Urgently needed services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 16, 2020 and October 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).
You say that the enrollee's pain has not responded to current treatments and remains persistent. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process spacer devices remain experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided by an out-of-network provider from September 10, 2020, through October 21, 2020.
You asked the Plan to pay for the outpatient services. You say that your plan is denying payment for treatments which is limiting essential medication prescription coverage for your current medical conditions. The Plan denied your request. The Plan says a Plan provider must be used, and H codes are not acceptable under Medicare.
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 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 outpatient services provided by an out-of-network provider from September 10, 2020, through October 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring provided on April 30, 2019.
You asked the Plan to pay for intraoperative neurophysiology monitoring. You say that your records indicate the claim was filed timely. The Plan denied your request. The Plan says this claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for intraoperative neurophysiology monitoring was not filed until July 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for intraoperative neurophysiology monitoring provided on April 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. 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 payable.
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 laboratory services provided on May 19, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study (CPT code 93926), Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT Code 93925), complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (CPT Code 93923) and, limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (CPT Code 93922), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that the Medicare rules have not been 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 services. Our physician reviewer found the enrollee has intermittent claudication in both legs. The record indicates that the enrollee has chronic venous insufficiency and underwent saphenous vein ablation. The enrollee underwent right popliteal stenting and anterior tibial angioplasty. The enrollee's most recent arterial studies were in August 2020 and did not demonstrate new greater than 50% reduction in left mid superficial femoral artery. The enrollee has progression of disease demonstrated by imaging. The enrollee has had interventions requiring follow-up. The elements of the coverage criteria are satisfied. The requested service is recommended. 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 been met. Therefore, we decided that the Plan has to pre-approve Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study (CPT code 93926), Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT Code 93925), complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (CPT Code 93923) and, limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (CPT Code 93922), 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 2, 2020.

You asked the Plan to pay for drug test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation does not support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services fifteen (15) hours a week, under the supervision of a physician with at least three (3) visits weekly to regain or maintain your functional status. You do not appear to be medically stable or ready for discharge from the acute hospital. The discharge to acute inpatient rehab is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 genetic testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence of a family history of cancer that would meet the criteria.
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 the medical record does not indicate that the enrollee has a close blood relative with breast by age 50,
invasive ovarian, pancreatic cancer, or prostate cancer with Gleason score of at least 7. The elements of the
coverage determination are not satisfied.
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 BRCA 1 and 2 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional Invitae Prostate Cancer Panel services (81479)
provided on June 10, 2020.

You asked the Plan to pay for the Invitae Prostate Cancer Panel. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the performance of multiple
molecular tests regardless of whether the requisition lists the tests as a panel or individually, and completed on
a single sample is considered to be a Panel of tests and should be billed under a single CPT code to prevent
stacking of codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 81479 is not supported in the record. Specifically, it is not appropriate to bill CPT code
81479 for the Invitae Prostate Cancer Screening more than once. Based on this information, we decided that
Medicare rules for coverage of the Invitae Prostate Cancer Panel have not been met. Therefore, we decided that
the Plan does not have to pay for the additional Invitae Prostate Cancer Panel services (81479) provided on
June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on December 14, 2020 by an OON provider.

You asked the Plan to pay for the resin-based composites. You say that you were under the impression that this provider was in-network with your plan. The Plan denied your request. The Plan says this service is not covered under your plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on December 14, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular testing provided on December 2, 2020.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because denying Guardant360 is a conflict with NCCN national practice guidelines for treating patients with advanced solid tumor cancers. The Plan denied your request. The Plan says as the member was considering hospice, and any treatment option would negatively affect his quality of live, genomic testing was not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Guardant360 testing may be covered when the patient has decided to seek further cancer 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 pay for the Guardant360 testing. Our reviewer says that the member does not meet LCD criteria for coverage for the Guardant360 testing. Our physician reviewer found as the member was considering hospice, and any treatment option would negatively affect his quality of live, genomic testing was not 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 Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular testing provided on December 2, 2020.