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

We decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code 81479) provided to the enrollee on October 1, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says this service 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. 

Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code 81479) provided to the enrollee on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when required (D2950), and extraction (D7140) provided on February 1, 2021.

You asked the Plan to pay for the crown, core buildup, and extraction. You say that these services were necessary, and you believe they should be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 crown (D2740), core buildup, including any pins when required (D2950), and extraction (D7140) provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on March 12, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit since it was a medical vision check (cataracts, intraocular lens, vitreous degeneration). Eye refractions are only covered by your plan if performed by a participating provider and performed as a routine vision screening.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 

We looked at the file and the Plan's rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care provided from November 23, 2020, to January 25, 2021.

You asked the Plan to waive the copayments for the wound care services. You say that you should have a $0 copay for specialist services. The Plan denied your request. The Plan says you had services in an outpatient program at the hospital therefore you were charged the copayments 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 $150 copayment for each visit to an outpatient hospital facility for outpatient hospital services.

You have been asked to pay a $150 copayment for each visit to an outpatient hospital facility for the wound care services. The wound care services fall within the outpatient hospital 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 copayments for wound care provided from November 23, 2020, to January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code(s): 81286, 81407, 81408, 81479) provided to the enrollee on September 4, 2020.

You asked the Plan to pay for the laboratory testing. You say that the services were medically necessary. 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. 

Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code(s): 81286, 81407, 81408, 81479) provided to the enrollee on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic (CPT code 81479) provided to the enrollee on January 19, 2021.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says only the GeneSight Psychotropic Multi-gene assay is covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. The rules say that a multi-gene panel is considered reasonable and necessary if more than one single gene on that panel would be considered reasonable and necessary for safe use of the medication in question or if multiple drugs are being considered (each fulfilling the criteria of actionable gene-drug interactions identified above) that have different relevant genes. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic (CPT code 81479) provided to the enrollee on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing (CPT code 0223U) provided to the enrollee on December 9, 2020.

You asked the Plan to pay for the laboratory testing. You say that this service is covered by Medicare. The Plan denied your request. The Plan says this service 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. 

As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing (CPT code 0223U) provided to the enrollee on December 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz FX injection for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc and don't require
prior authorization.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 drug. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan,
requires these be trialed first. The documentation does not outline contraindications or reasons these
medications were not considered. Without the support of the documentation, Supartz FX is not approved, as
step criteria have not been met.

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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Supartz FX injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) provided on January 13, 2021, to February 1, 2021, by an out of network (OON) provider.
You asked the Plan to pay for chiropractic manipulative treatment. You say that you visited this provider last year and claims were not denied. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization. The Plan also says that there are in-network providers available for these services.
Medicare rules say that except for emergency and urgently needed services, Cost 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 contract with the Plan says that if you receive Medicare-covered services (except for emergency or urgent care) from an out-of-network provider, these services will be paid for by Original Medicare, not the Plan. 
You indicate that you previously had claims paid for service with this provider. The records show that there are no previous claims found for this provider. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 chiropractic manipulative treatment (98941) provided on January 13, 2021, to February 1, 2021, by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 22, 2020.

You asked the Plan to pay for the laboratory services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 laboratory services provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom compression stockings.
You asked the Plan to pre-approve the custom compression stockings. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the custom compression stockings.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services, medical examination and evaluation provided on March 16, 2021.

You asked the Plan to waive the copayment for the ophthalmological services, medical examination and evaluation. The Plan denied your request. The Plan says you pay $40 for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.

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 vision care, Medicare-covered outpatient visit. 

You have been asked to pay a $40 copayment for the ophthalmological services, medical examination and evaluation. The ophthalmological services, medical examination and evaluation falls within the vision care, Medicare-covered outpatient 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 copayment for ophthalmological services, medical examination and evaluation provided on March 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on January 4, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that per internal hospital notes, authorization was not required for an outpatient colonoscopy. You seek to recover charges for medically necessary services rendered by the facility as supported by the medical records. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient hospital services provided on January 4, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on December 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid due to medical necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 pain management services provided on December 11, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (84153) provided January 27, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 
In this case, the MUE for CPT code 84153 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (84153) provided January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and complete series of intraoral x-rays (D0210) provided on March 15, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation and complete series of intraoral x-rays. You say that you are wondering whether these services were denied as out-of-network, or member not being eligible for coverage. The Plan denied your request. The Plan says you did not enroll in the dental rider, and your dental eligibility termed as of January 1, 2021. The Plan also says that there is no authorization on file, and no calls prior to this date of service to check your dental benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and complete series of intraoral x-rays (D0210) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral facet joint block.

You asked the Plan to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral: single level (64493). You say that the enrollee has had a recent return of pain. The Plan denied your request. The Plan says the records do not show 50% pain relief or why the enrollee is not a candidate for radiofrequency ablation.

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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral: single level (64493). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD limits the injections to 2 levels at one session. The LCD requires an explanation of why the patient is not a candidate for radiofrequency ablation of the Medial Branch Blocks. Because of the lack of documentation, the request is considered not medically reasonable or 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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral: single level (64493) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar-sacral facet joint block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
You asked the Plan to pre-approve a portable home ventilator. You say that this ventilator is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 
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 a portable home ventilator. Our reviewer says that the requested ventilator is not medically necessary. Our physician reviewer found this patient has COPD with chronic hypercarbic respiratory failure, as well as pulmonary fibrosis, pulmonary hypertension, and heart failure with preserved ejection fraction. She may benefit from nocturnal bi-level positive airway pressure at home, which apparently has not been tried. Medicare does not cover a home ventilator when used as bi-level positive airway pressure device. 
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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for headphones provided on August 7, 2020.

You asked the Plan to reimburse you for the headphones. The Plan denied your request. The Plan says your policy covers $300.00 for hearing aids supplied by a physician, audiologist, or other qualified provider.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 

We looked at the file and Medicare rules. You purchased the headphones from an online company that is not a provider or a supplier that is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for headphones provided on August 7, 2020.