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

We decided that the Plan does not have to pay for molecular and genomic testing for the enrollee.You asked the Plan to pay for the testing. You say that this is medically necessary.The Plan denied your request. The Plan says the clinical information received did not establish medical necessity for the requested service.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 pay for the testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have hematuria in the setting of BPH, a rising PSA level and a known renal mass. Pharmacogenetic testing has been ordered to apparently see if the enrollee's anticoagulants (Plavix, ASA) are contributing to his hematuria. Such testing will not diagnose the hematuria nor usurp the risk/benefit ratio of taking the anticoagulants. There is no clear evidence as to how this testing will affect management of the patient. As such, the requested testing is not shown to be medically necessary or reasonable.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay for molecular and genomic testing for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4Kscore testing (81539).
You asked the Plan to pre-approve 4Kscore testing. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says 4Kscore testing is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say 4Kscore testing is not covered.
We looked at the file and Medicare rules. Medicare says that due to significant issues with assay validation and
absence of clinical utility, 4Kscore testing is not reasonable and necessary and is not covered by Medicare.
Therefore, we decided that the Plan does not have to pre-approve 4Kscore testing (81539).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 7, 2020.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 physician services provided to the enrollee on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist services rendered on February 14, 2020 ad February 20, 2020.You asked the Plan to waive the copayments forthese services. You say that you disagree with the charges.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 $25 copayment for each specialist's office visit. Review of the file shows that you received specialist services on February 14, 2020 and February 20, 2020. You have been asked to pay a $25 copayment per date of service for these services, for a total of $50. These services fall within the specialist's office visit 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 copayments forthe specialist services rendered on February 14, 2020 ad February 20, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ECG provided on December 28, 2019.You asked the Plan to pay for the ECG.You say that this visit was not related to the enrollee's hospice stay.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the ECG provided on December 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on May 22, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without HCPCS G0482: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that Current Procedural Terminology (CPT) code 80307 remains not supported. According to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. Review of claims history for this enrollee, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. The review has determined that the records do not support the above denied codes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a repeat duplex scan of extracranial arteries (93880) provided
on August 14, 2019.
You asked the Plan to pay for a repeat duplex scan of extracranial arteries. You say that this should be paid.
The Plan denied your request. The Plan says the records do not support an additional study and one unit of this
code has previously been billed and paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for a repeat duplex scan of extracranial arteries
Our reviewer says that the billing of a second unit of 93880 is not supported. Our physician reviewer found the
submitted medical records do not document that a repeat procedure or second unit took place.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a repeat duplex scan of extracranial arteries have not been met. Therefore, we
decided that the Plan does not have to pay for a repeat duplex scan of extracranial arteries (93880) provided on
August 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation
(97112), gait training therapy (97116), group therapeutic procedures (97150), and the therapeutic activities
(97530) provided January 1, 2020 to January 31, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were provided 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan
does not have to pay for the therapeutic exercises (97110), neuromuscular reeducation (97112), gait training
therapy (97116), group therapeutic procedures (97150), and the therapeutic activities (97530) provided
January 1, 2020 to January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forEpifix (Q4186) and the application of low cost skin substitute (C5273, C5274) provided on December 23, 2019.You asked the Plan to pay forEpifix and the application of low cost skin substitute. You say that these procedures should be covered.The Plan denied your request. The Plan says this was not billed correctly.The Plan follows Medicare rules. The rules say that claims containing a high cost skin substitute application procedure without any of the high cost skin substitute product codes, and conversely any low cost skin substitute application procedure without a low cost skin substitute product code for the same day, are returned to the provider.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skin substitute applications (C5273, C5274) have not been met. Specifically, these are low cost skin substitute applications. The record shows that these were billed with code Q4186, a high cost skin substitute.Therefore, we decided that the Plan does not have to pay forEpifix (Q4186) and the application of low cost skin substitute (C5273, C5274) provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 9, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on January 2, 2020.You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported by the records.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 orthoses and sleeves have not been met. Healthcare Common Procedure Coding System (HCPCS) code L1851 RT KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code L1851 LT KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.Healthcare Common Procedure Coding System (HCPCS) code L2397 RTKX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.Healthcare Common Procedure Coding System (HCPCS) code L2397 LT KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care from February 20, 2020 through February 21,
2020.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan
denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. the stay was medically necessary. Therefore, we decided that the Plan has to pay
for inpatient hospital care from February 20, 2020 through February 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mobile x-ray services (73610, R0070, Q0092) provided on November 8, 2019.You asked the Plan to pay forthe mobile x-ray services. You say that the services were medically necessary and should be covered.The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.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 has network providers available who can provide 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 forthe mobile x-ray services (73610, R0070, Q0092) provided on November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 27, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on August 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) during nonintracranial
surgery (eg, carotid surgery) coded 95955 provided on April 8, 2019.
You asked the Plan to pay for the electroencephalogram (EEG) during nonintracranial surgery. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
rendered are not medically necessary.
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 pay for the electroencephalogram (EEG) during
nonintracranial surgery. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee had a lumbar laminectomy/
Discectomy/ Foraminotomy L1-L5. In this case, the enrollee went to surgery with no neurological concerns or
deficits per review of submitted clinical records. Intraoperative EEG in the setting of spine surgery is unproven.
Therefore, the enrollee did not meet criteria for the rendered 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 the electroencephalogram (EEG) during nonintracranial surgery have not been
met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) during
nonintracranial surgery (eg, carotid surgery) coded 95955 provided on April 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pelvic and bladder surgery with an out-of-network
tertiary care provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services can
be provided by an in-network provider.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested tertiary care services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that utero-vaginal prolapse surgery can usually be performed in a non-tertiary care
setting. The enrollee has not yet been evaluated by an in-network, non-tertiary provider.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve pelvic and bladder surgery with an out-of-network tertiary care provider.
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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was medically stable. The enrollee required minimal assistance for
walking 88 feet in divided sessions with a front wheeled walker. The enrollee required stand-by assistance with
transfers. The documentation does not support that the enrollee requires the need for supervision by physical
medicine and rehabilitation Physician or needs acute rehab nursing care. While the enrollee may benefit from
further physical therapy and occupational therapy, the enrollee does not require an intensive therapy program.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment charged for outpatient services provided on February 13, 2020.You asked the Plan to waive the $295 copayment. We note the Plan stated the original charge of $475 was reduced to $295. You say that you do not believe this copayment is correct.The Plan denied your request. The Plan says you were originally charged the incorrect copayment of $475, which has now been reduced to $295.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 for outpatient surgery. You are now being 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 charged for outpatient services provided on February 13, 2020.