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

We decided that the Plan does not have to pay for the office visit rendered on June 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the office visit is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99212 (office visit) and 01402 (anesthesia for knee
arthroplasty). Code 99212 is a column II code with a modifier indicator of 1 when billed with column I code
01402. Code 99212 was not billed with an appropriate modifier to allow for separate payment. Therefore, we
decided that the Plan does not have to pay for the office visit rendered on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services: medical examination and
evaluation, with initiation or continuation of diagnostic and treatment program (92012), fundus photography
with interpretation and report (92250), progressive lenses (V2781), and frames (V2020) provided May 19,
2021.
You asked the Plan to pay for the eye exam with photos and routine eyewear. You say that you haven't had an
eye exam in 2 years and did not know the provider was out-of-network. The Plan denied your request. The Plan
says these services are not covered because the provider is out-of-network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers the eye exam with photos when rendered by a network 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. We found no exception that would require the Plan to pay for the eye exam with photos.
The routine eyewear is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for
the ophthalmological services: medical examination and evaluation, with initiation or continuation of
diagnostic and treatment program (92012), fundus photography with interpretation and report (92250),
progressive lenses (V2781), and frames (V2020) provided May 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 16, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment from October 15, 2021, forward. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment from October 15, 2021, forward. Daily skilled services are not required from October 15, 2021, forward. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case from October 15, 2021, forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from October 16, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by a chiropractor on January 13,
2021.
You asked the Plan to pay for the office visit (99213). You say that the treatments included manual
manipulation of the spine and are a covered benefit. The Plan denied your request. The Plan says office visits
provided by a chiropractor are never 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 is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the office visit provided by a chiropractor on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure code 87798) provided to the
enrollee on February 18, 2021.
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 the records do not support the services billed.
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 87798 is "Infectious agent detection by nucleic acid
(DNA or RNA), not otherwise specified; amplified probe technique, each organism."
We find that CPT code 87798 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 laboratory services (procedure code
87798) provided to the enrollee on February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from April 14, 2021, to April 16, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were only told about copayments for emergency visits and ambulance services. You didn't have those and you didn't have any operation, so you don't think you should pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $365 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for two days. You have been asked to pay a $365 copayment per day for, for a total of $730. 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azathioprine.

You asked the Plan to pre-approve Azathioprine. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Azathioprine.

Benefits for Azathioprine 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 pre-approve percutaneous electrical nerve stimulation (PENS).
You asked the Plan to pre-approve PENS. 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 no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific conditions are 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 PENS. Our reviewer says that the
services are not medically necessary. Our physician reviewer found there is no evidence that this system works in the setting of chronic low back pain. The request is 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 PENS have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic screening for prostate cancer for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found prostate biomarker testing is covered prior to initial biopsy with moderately elevated PSA. The records 
indicate that this enrollee has already had a prostate biopsy. 
 
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 pre-approve genetic screening for prostate cancer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hernia surgery (49565) provided to the enrollee on January 25, 2021.
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 the claim was denied 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. In this case, the CPT Code Manual definition of code 49565 is "Repair recurrent incisional or ventral hernia; reducible." We asked our coder 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 reviewer found the medical records provided do not include sufficient documentation to validate that 46965 was performed as a distinct, separate service on January 25, 2021, therefore this service is not eligible for separate reimbursement.
We looked at this coder'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 hernia surgery (49565) provided to the enrollee on January 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for proton beam radiation treatment (77523) Radiation treatment management, 5 treatments (77427) Computed tomography guidance for placement of radiation fields (77014) provided March 29, 2021.
You asked the Plan to pay for the diagnostic services. You say that the enrollee is on an approved clinical trial where Medicare pays as primary 80% of the allowable and the Plan pays the remaining 20%, per the CMS
Medicare Advantage reimbursement guidelines for clinical trials. The Plan denied your request. The Plan says care not approved in compliance with the health Plan's authorization procedures. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage Organization's pay the enrollee the difference between original Medicare cost-sharing incurred for qualified clinical trial items and services and the MA plan's in-network cost-sharing for the same category of items and services. We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare criteria for coverage have not been met. Specifically, the Plan is responsible for paying the difference between the original Medicare cost-sharing incurred for qualified clinical trial items and services and the MA plan's in-network cost-sharing for the same category of items and services. In this case, both the Plan and Medicare assess a 20% coinsurance so there is no difference to be paid. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for proton beam radiation treatment (77523) Radiation treatment management, 5 treatments (77427) Computed tomography guidance for placement of radiation fields (77014) provided March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be performed by a chiropractor.
You asked the Plan to pre-approve office visit. You say that when you go to a chiropractor it temporarily helps your condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor.
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 is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve an office visit to be performed by a chiropractor.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax.
You asked the Plan to pre-approve a CT scan of the thorax. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the thorax. Our reviewer says that the services are medically necessary. Our physician reviewer found the pathology results were equivocal and re biopsy was suggested. However, due to lung disease and the history of pneumothorax it is reasonable to re scan the lung nodule to determine if it has grown particularly in light of the equivocal pathology report and the abnormal positron emission tomography (PET) scan. 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 CT scan of the thorax have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax.
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 Vitamin D assay rendered on June 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D assay rendered on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intra-articular facet joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered not medically necessary at this time and cannot be approved.
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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the facet joint is not the main source of pain. The pain is associated with radiculopathy. There is not a
clear indication for the requested injection.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve an intra-articular facet joint injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical services provided to the enrollee on November 20, 2020.

You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says care must be received from a network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.

Therefore, we decided that the Plan does not have to pre-approve surgical services provided to the enrollee on November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on June 5, 2021.
You asked the Plan to pay for the services provided. You say that the services are separately payable. The Plan denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE. The file shows that 2 units of this service have been paid for by the Plan. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to further pay for the critical care services provided on June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit provided on May 25, 2021.
You asked the Plan to reimburse you for the office visit (99215). You say that the claims have been paid in the past. The Plan denied your request. The Plan says the provider opted out of Medicare and therefore the claim cannot be paid. The previous claims were paid in error.
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 services at issue in this appeal were 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 reimburse you for the office visit provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot (L4361), provided on April 22, 2021.
You asked the Plan to waive the coinsurance for the walking boot. You say that the item should be covered. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Durable Medical Equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the walking boot. the walking boot falls within the Durable Medical Equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the walking boot (L4361), provided on April 22, 2021.