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

We decided that the Plan does not have to pay for the molecular pathology provided on July 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the molecular pathology. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out of network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 molecular pathology provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids received on June 12, 2020.

You asked the Plan to pay for hearing aids. You say that you would like the Plan to pay. The Plan denied your request. The Plan says the items were received from an out-of-network provider and are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when you utilize an in-network provider. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network provider and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids received on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management of an established patient provided on December 15, 2020 by an out of network provider.
You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an established patient (99335). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the telemedicine service.
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 service 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 evaluation and management of an established patient provided on December 15, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.

You asked the Plan to pre-approve Restasis. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis.

Benefits for Restasis may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin graft services rendered October 8, 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 15271 and 15272 are 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 15271 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. The definition of code 15272 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). We find that CPT codes 15271 and 15272 are not supported in the medical record. Specifically, the codes were billed without any high cost skin substitute products billed. 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 skin graft services rendered October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided on August 4, 2020 by an out of network (OON) provider.
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.
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 nursing facility visit provided on August 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered on December 15, 2020.
You asked the Plan to waive the copayment for these services. You say that the services didn't work so you shouldn't have to pay for them. 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 $10 copayment for visits to an in-network primary care provider.
Review of the file shows that you received primary care physician services on December 15, 2020. Per the contract with the Plan, there is a $10 copayment for visits to an in-network primary care provider. 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 $4.20. Given that the allowed amount was less than the $10 copayment, you have been asked to pay $4.20 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the physician services rendered on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the eye exam and imaging rendered on November 23, 2020.
You asked the Plan to waive the copayments for these services. You say that you were advised there would be no copayment. The Plan denied your request. The Plan says the copayments were 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 $40 copayment for each Medicare-covered exam to treat an eye condition and a $65 copayment for each covered diagnostic procedure or test at a network doctor's office.
Review of the file shows that you had an eye exam on November 23, 2020. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered exam to treat an eye condition benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received external ocular imaging services on November 23, 2020. Per the contract with the Plan, there is a $65 copayment for each covered diagnostic procedure or test at a network doctor's office. However, the Medicare allowed amount for these services was $27.51. Given that the allowed amount was less than the $65 copayment, you have been asked to pay $27.51 for these services.
The total amount you have been asked to pay for these services is $67.51. 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 copayments for the eye exam and imaging rendered on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services rendered on August 26, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that telehealth services must be billed with the -GT modifier. We looked at the file and Medicare rules. The provider billed code 99214 (office visit) with modifier -GT. The file shows that the services were a face-to-face encounter for which the -GT modifier does not apply. Therefore, we decided that the Plan does not have to pay for the telehealth services rendered on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 3, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO) provided on June 19, 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 this provider is not Medicare certified and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for Medicare-covered items, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not payable. 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 (LSO) provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional splinting - extracoronal (D4321) provided November 17, 2020.
You asked the Plan to pay for the provisional splinting. You say that this was an important procedure and should be covered. The Plan denied your request. The Plan says the service is not covered under your dental benefit and was provided by an out-of-network provider.
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 provisional splinting - extracoronal (D4321) provided November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on January 21, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health stay.
You asked the Plan to pre-approve inpatient mental health stay. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active 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 pre-approve inpatient mental health stay. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of May 3, 2021 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. He was being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health stay have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81235, 81321, 81408) provided on December 9, 2020.
You asked the Plan to pay for genetic testing. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. To report a CGP service, test providers should use CPT code 81479. We find that CPT codes 81235, 81321, 81408 are not supported in the medical record. Specifically, the testing at issue is considered a CGP service and should be reported with 81479. 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 genetic testing (81235, 81321, 81408) provided on December 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on September 29, 2020.

You asked the Plan to waive the copayment for ambulance transport. You say that this is the only emergency medic in your area, so you had no other option. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $295 copayment for each one-way ambulance trip. 

You have been asked to pay $295 copayment for ambulance transport. Ambulance transport falls within the Ambulance 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 ambulance transportation provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) provided on February 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as it was rendered by a provider who has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The service at issue in this appeal was provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) provided on February 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.

You asked the Plan to pre-approve Opdivo. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Nivolumab is not FDA approved for the treatment of locally advanced vulvar cancer. Use is not supported by the medical literature of major drug compendia. The service is not reasonable or 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroplasty.
You asked the Plan to pre-approve sacroplasty. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous vertebral augmentation (PVA or Kyphoplasty) procedures are covered when specific criteria have 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 sacroplasty. Our reviewer says that the services are not medically necessary. Our physician reviewer found sacroplasty remains experimental for the treatment of sacral insufficiency fractures and back pain. 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 sacroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroplasty.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunofixation electrophoresis rendered on October 8,
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 86335 is not covered.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
We looked at the file and Medicare rules. Billed procedure code 86335 has a status indicator of X and is
statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the
immunofixation electrophoresis rendered on October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided September 30, 2019 to October 5, 2019.
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 193. 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 inpatient hospital care. Our reviewer says that DRG 193 is not supported in the records. Our physician reviewer found the records do not support DRG 193. The DRG change to 189 was appropriate based on the records provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided September 30, 2019 to October 5, 2019.