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

We decided that the Plan does not have to pay for the laboratory services rendered on October 6, 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 the services have already been paid.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 for the laboratory services rendered on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2020.
You asked the Plan to pay for the laboratory 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36473).
You asked the Plan to pre-approve endovenous ablation therapy. You say that the requested services are a
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested treatment is
experimental/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 endovenous ablation therapy. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that, in the setting of possible significant peripheral artery disease, ablation of
the enrollee's saphenous veins bilaterally cannot at this point be deemed 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 endovenous ablation therapy have not been met. Therefore, we decided that the
Plan does not have to pre-approve endovenous ablation therapy (36473).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided by a participating provider on December 24, 2020, to February 25, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you should not have to pay for this because it was a result of an issue that stemmed from an outpatient surgery. 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 $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $40 copayment for outpatient rehabilitation services. The total amount you are being asked to pay is $320 ($40 x 8 = $320). Outpatient rehabilitation services falls within the outpatient rehabilitation services/in-network 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 outpatient rehabilitation services provided by a participating provider on December 24, 2020, to February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room and ancillary services provided on December 27, 2020, through December 29, 2020.
You asked the Plan to pay for the emergency room and ancillary services. You say that you would like reconsideration because these services were medically necessary for symptom management as the member would have received these services regardless of level of care and are considered post stabilization services. The Plan denied your request. The Plan says these charges should be carved out and billed separately from the inpatient charges.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the emergency room and ancillary services are not supported in the record. Specifically, in order to bill for these services, they must be separated and billed separately from the inpatient charges. Based on this information, we decided that Medicare rules for coverage of the emergency room and ancillary services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room and ancillary services provided on December 27, 2020, through December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on January 6, 2021, to February 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for durable medical equipment. You say that you have asked to the Plan to send you a list of in-network providers multiple times. The Plan denied your request. The Plan says prior authorization was not obtained by your primary care physician. The Plan says that there are in-network providers available for these services.
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 durable medical equipment provided on January 6, 2021, to February 3, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on November 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 24, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 5, 2020.
You asked the Plan to pay for drug testing. 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 submitted shows that the sample for this testing was taken in an office setting, therefore the 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81406, 81479) provided on December 21, 2020.

You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81406, 81479) provided on December 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 you have no skilled therapy or skilled nursing service needs.
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 your condition does not meet
Medicare criteria for continued 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 continued skilled nursing facility (SNF) services.
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 medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 patient was admitted to an acute care hospital for knee replacement surgery.
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. The patient does require physical and occupational therapy but there is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, two subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia, and therapeutic parenteral drug provided on December 30, 2020.

You asked the Plan to pay for the removal of residual tooth roots, intravenous moderate (conscious) sedation/analgesia, and therapeutic parenteral drug. You say that you believe these services should 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 removal of residual tooth roots, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, two subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia, and therapeutic parenteral drug provided on December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyaluronan or derivative, GenVisc 850, for intraarticular
injection, 1 mg (J7320).
You asked the Plan to pre-approve GenVisc 850. You say that the item is medically necessary. The Plan denied
your request. The Plan says the item is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 GenVisc 850. Our reviewer says that
the item is not medically necessary. Our physician reviewer found the enrollee has not had a prior trial of
steroid injections.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of GenVisc 850 have not been met. Specifically, the enrollee did not receive a
prior trial of steroid injections. This means the LCD criteria have not been met, and therefore, the item is not
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve
hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg (J7320).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on June 12, 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 code 97110 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 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 records show that the services were performed in the home setting and there is a more appropriate code for these services.

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 for the physical therapy services rendered on June 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for dialysis provided by an out-of-network provider on December 11, 2020, December 14, 2020, and December 28, 2020.You asked the Plan to pay for the dialysis. You say that the patient was traveling during this time, so the dialysis treatments were received at a different facility. You say that the services were medically necessary, and the claim should be reprocessed for payment.The Plan denied your request. The Plan says that out-of-network providers must obtain authorization before services are rendered.Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.Based on this information, we decided that Medicare rules for coverage of the dialysis have been met.The out-of-area dialysis services were received at a Medicare-certified dialysis facility. Therefore, we decided that the Plan has to pay for dialysis provided by an out-of-network provider on December 11, 2020, December 14, 2020, and December 28, 2020.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.

You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 recliner chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01480) provided on November 4, 2020.
You asked the Plan to pay for anesthesia. You say that this was billed correctly. The Plan denied your request. The Plan says the billed units aren't supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 114 units of CPT code 01480 are not supported in the medical record. The medical record only supports 96 minutes of CPT code 01480. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01480) provided on November 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital observation services
provided by an out-of-network provider on December 30, 2019.

You asked the Plan to waive the coinsurance for outpatient hospital observation services. You say that this
coinsurance is too high. The Plan denied your request. The Plan says the correct coinsurance 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 50%
coinsurance for outpatient hospital services/out-of-network.

You have been asked to pay a 50% coinsurance of the allowed amount for outpatient hospital observation
services. The total allowed amount is $4,192.30. The total amount you are being asked to pay is $2,096.15
($4,192.30 x 50% = $2,096.15). Outpatient hospital observation services fall within the outpatient hospital
services/out-of-network 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 coinsurance for outpatient hospital observation services provided by an out-of-network provider on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) supplies rendered on February 1, 2021.

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 the services were rendered by an out-of-network provider without prior authorization.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) supplies rendered on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve naturopathic services.
You asked the Plan to pre-approve naturopathic services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pre-approve naturopathic services.