Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary level cardiology referral.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says that you can be treated at the in-network community-based cardiology provider.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the referral. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have been treated with investigational/new technology at a tertiary center as part of a Medicare approved trial. Regular follow-up from clinicians familiar with these investigational devices for both clinical visits and follow-up imaging of these devices absolutely require the expertise of the supervising physicians of the trial familiar with their specific characteristics and likely complications or device failures. Community based cardiologists have little or no experience with these investigational devices and as such would not be appropriate clinicians to provide the regular follow-up after these device implantations. As such, it is medically necessary and reasonable for you to continue with follow-up and imaging by the tertiary medical center clinicians. 

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 referral have been met. Therefore, we decided that the Plan has to pre-approve a tertiary level cardiology referral.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT code 82306) provided to the enrollee on October 22, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not authorized because code 82306 is not a Medicare benefit for the diagnoses listed on the claim and is done for screening purposes.

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 does not cover this test solely for screening purposes. The services are not authorized because code 82306 is not a Medicare benefit for the diagnoses listed on the claim and is done for screening purposes. The diagnosis listed for the enrollee is anemia. Therefore, we decided that the Plan does not have to pay for vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT code 82306) provided to the enrollee on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with evaluation and management services (99358, 99359, 99443) provided on February 6, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit with evaluation and management services. You say that the services were medically necessary. The Plan denied your request. The Plan says 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 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 an office visit with evaluation and management services (99358,
99359, 99443) provided on February 6, 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 FlowerAmnioFlo (Q4177) and injections (20550, 20553)
provided from November 11, 2020, to November 25, 2020.

You asked the Plan to pay for FlowerAmnioFlo and injections. You say that these services were medically
necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

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 FlowerAmnioFlo and injections. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found this is an experimental therapy for low back pain. There is no peer reviewed
literature that supports its use for this condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of FlowerAmnioFlo and injections have not been met. Therefore, we decided that
the Plan does not have to pay for FlowerAmnioFlo (Q4177) and injections (20550, 20553) provided from
November 11, 2020, to November 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination of femur provided on February 11,
2021.
You asked the Plan to pay for radiologic examination, femur; minimum 2 views (73552). You say that the Plan
should pay this claim. The Plan denied your request. The Plan says the code 77075 was billed by the same
provider on the same date of service.
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, we have confirmed that code
radiologic examination, femur; minimum 2 views (73552) has a bundled relationship with code 77075 and
cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for
radiologic examination of femur provided on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora bone density scan (77080) provided December 1, 2020.You asked the Plan to pay forthe bone density scan. You say that the service was medically necessary.The Plan denied your request. The Plan says the service was for screeningpurposes only and 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, the bone density scan, was requestedsolely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay fora bone density scan (77080) provided December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-manipulative  services from a  chiropractor (CPT code(s): 97012 and 97014) and CMT; spinal, 1-2 regions (CPT code 98940) provided on February 18, 2021, by an out-of-network provider.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue (CPT code(s):97012 and 97014) are not manual manipulation of the spine. Furthermore, CPT code 98940 is denied as the required modifier was not submitted. This service requires a AT or  GA or GZ or GX or GY, whichever is appropriate  per the CMS Guidelines.Therefore, we decided that the Plan does not have to pay forthe non-manipulative  services from a  chiropractor (CPT code(s): 97012 and 97014) and CMT; spinal, 1-2 regions (CPT code 98940) provided on February 18, 2021,by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic hearing test provided on February 24, 2021.You asked the Plan to waive the copayment fora diagnostic hearing test. You say that this was a routine hearing exam,and you should not be charged a copayment.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct amount.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 diagnostic hearing exams and a $0 copayment for routine hearing services. The medical records show that you received services beyond routine hearing services on February 24, 2021. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for a diagnostic hearing test. A diagnostic hearing test falls within the hearing services benefit category. This means that you have been asked to pay the correctamount 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 fora diagnostic hearing test provided on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forMTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (Current Procedural Terminology (CPT) code 81291) and CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) (CPT code 81225) provided to the enrollee on December 21, 2020.You asked the Plan to pay forthe laboratory services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services are not covered. 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 laboratory services have not been met. Per LCD L36400 MTHFR (81291) is not covered with the exception of pregnant patients therefore this member does not meet the criteria. Myriad or Assurex are notpart of the Plan for 81225.Therefore, we decided that the Plan does not have to pay forMTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (Current Procedural Terminology (CPT) code 81291) and CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) (CPT code 81225) provided to the enrollee on December 21, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299), skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes (G0300 x 10), and physical therapy in the home health or hospice setting, each 15 minutes (G0151 x 10).
You asked the Plan to pre-approve the home health services. You say that your provider advised that you would benefit from continued home health skilled nurse services for management of medication for pain and for pain management. The Plan denied your request. The Plan says you do not require skilled services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found you do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested home health services are not medically necessary We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299), skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes (G0300 x 10), and physical therapy in the home health or hospice setting, each 15 minutes (G0151 x 10).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81291, 81225, 81240, 81241, 81407, 81406,
81408, 81408, 81230, 81249) provided November 20, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says The Plan says the services cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that when a laboratory assays two or more genes in a
patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a
single procedural service, so one CPT code must be submitted for the panel.
We looked at the file and Medicare rules. In this case, multiple CPT codes were billed for the genetic testing
panel. Unbundled codes cannot be paid. Based on this information, we decided that Medicare rules for
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for
genetic testing (81291, 81225, 81240, 81241, 81407, 81406, 81408, 81408, 81230, 81249) provided November
20, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for the cutting of a lesion and the nail debridement. We decided that the Plan does not have to waive the cost share for the office visit.

You asked the Plan to waive the cost share for the office visit, the cutting of a lesion, and the nail debridement. You say that you visited the foot doctor and are being billed for services were not rendered. The Plan says that you have been charged the correct cost sharing amount.

We decided that the Plan has to waive the cost share for the cutting of a lesion and the nail debridement.

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 Plan did not submit the medical records. This means we cannot confirm that the cutting of a lesion and the nail debridement were rendered. Therefore, we decided that the Plan has to waive the cost share for the cutting of a lesion and nail on February 3, 2020.

We also decided that the Plan does not have to waive the cost share for the office visit.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as co-payments, deductibles, and coinsurance). The office visit you asked the Plan to waive the deductible for falls within the "Podiatry care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $390 deductible that applies towards office visits. This cost sharing is a contractual obligation that had not been met at the time. The allowed amount for the office visit was $80.55 which was applied to the deductible. Therefore, we decided that the Plan does not have to waive the cost share for the office visit.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s):
81404, 81405, 81479) provided to the enrollee on November 18, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not covered. 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 testing have not been met. 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
the cardiovascular risk assessment testing (CPT code(s): 81404, 81405, 81479) provided to the enrollee on
November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
January 19, 2021.

You asked the Plan to pay for the office visit. You say that the patient had a complex problem requiring the
attention of a gynecologic oncologist for surgery and treatment. You say that the patient was referred by her
primary care physician and the claim should be processed for payment. The Plan denied your request. The Plan
says prior authorization is required for non-participating providers.

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 office visit provided by an out-of-network
provider on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 1, 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. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fortopical application of fluoride (D1206), an intraoral periapical radiographic image (D0220), and a crown (D2740) provided from February 1, 2021, through February 10, 2021.You asked the Plan to pay fortopical application of fluoride, an intraoral periapical radiographic image, and a crown. Yousay that you were not aware that your benefits changed for the new year.The Plan denied your request. The Plan says the services at issue are not covered benefits.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 fortopical application of fluoride (D1206), an intraoral periapical radiographic image (D0220), and a crown (D2740) provided from February 1, 2021, through February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
the intraoral - periapical first radiographic image (D0220) received January 28, 2021, from the out-of-network
provider.
You asked the Plan to pay for the dental services. You say that you did not know that you were required to see
a particular dentist. The Plan denied your request. The Plan says services received out-of-network are not
covered under your supplemental benefit.
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 when they are received out-of-network. Therefore, we decided that the
Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and the intraoral -
periapical first radiographic image (D0220) received January 28, 2021, from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), and the
unspecified preventive procedure, by report (D1999) received November 10, 2020.
You asked the Plan to pay for the panoramic radiographic image and the unspecified preventive procedure.
You say that the plan covers x-rays and therefore these procedures should be covered. The Plan denied your
request. The Plan says you only have coverage for bitewing x-rays. Panoramic radiographic images are not
covered under your benefit.
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 panoramic radiographic image (D0330), and the unspecified preventive procedure, by report (D1999) received November 10, 2020.