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

We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the
enrollee on April 26, 2021.
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
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 the
ultrasound has a bundled relationship with code 76705 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. Review of
records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between 76705 and 93976. This PTP edit has a modifier indicator of 1, which indicates modifiers associated
with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705)
provided to the enrollee on April 26, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from December 15, 2020, through December 30, 2020.

You asked the Plan to pay for the inpatient care. You say that the services are non-work related. The Plan denied your request. The Plan says that the Plan has determined that this is a work-related injury and therefore according to CMS guidelines, workers compensation must provide benefits first for any healthcare costs related to your job-related illness or injury before the Plan will provide any benefits.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the inpatient care until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for inpatient care provided from December 15, 2020, through December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the genetic testing (CPT code (s): 81292, 81295, 81298, 81317).
You asked the Plan to pre-approve the genetic testing. You say that current genetic testing recommendations include that individuals with absent proteins in the tumor should be evaluated for Lynch syndrome and consideration of germline genetic testing to further assess. The Plan denied your request. The Plan says documentation does not support how the results of this test will directly impact treatment decision making, your treatment plan, or your clinical management.
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 genetic testing. Our physician reviewer found since the provider states that treatment will not change based on these test results, this requirement has not been met. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the genetic testing (CPT code (s): 81292, 81295, 81298, 81317).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays provided on May 4, 2021, by an OON provider.

You asked the Plan to pay for x-rays. You say that the member's primary care physician referred these services.
The Plan denied your request. The Plan says there are in-network providers available for these services.

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 x-rays provided on May 4, 2021, by an OON
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 29, 2021, to April 30, 2021.
You asked the Plan to pay for the self-administered drugs. You say that services were part of the shoulder replacement procedure and you are appealing the denial. The Plan denied your request. The Plan says these services are not covered by Medicare.
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 pay for the self-administered drugs provided from April 29, 2021, to April 30, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (36000) provided on January 27, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee
Schedule indicates that payment for covered services is always bundled into payment for other services not
specified.

We looked at the file and Medicare rules. Code 36000 is assigned a status indicator of "B" under the Physician
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for
other services. No separate payment can be made for code 36000. 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 the services (36000) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a hiking course and a smart driver's course
(A9270) for the 2021 benefit allowance.
You asked the Plan to reimburse you for a hiking course and a smart driver's course. You say that you are a
member of the hiking club that walks for three hours every Wednesday. You also say that you were told by the
Plan that these services would be covered. The Plan denied your request. The Plan says these services are not a
covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the
Plan reimburses you up to $175 per calendar year towards your cost for membership in a qualified health club
or fitness facility, covered instructional fitness classes or participation in wellness programs.
The services at issue in this appeal are for health and wellness benefits. A hiking course is not a covered benefit
of Medicare or the Plan. The Plan can only reimburse you when valid receipts are submitted. The records show
that you did not submit valid proof of payment for the smart driver's course, therefore, we are unable to
approve this reimbursement. Therefore, we decided that the Plan does not have to reimburse you for a hiking
course and a smart driver's course (A9270) for the 2021 benefit allowance.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that without coverage the enrollee's ulcer can become worse. The Plan denied your request. The Plan says that the enrollee needs to stay in an acute care hospital until she is better.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT code 93976) provided to the enrollee on April 22, 2021.
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 Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Review of records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93976 and 76856. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT code 93976) provided to the enrollee on April 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on May 5, 2021.

You asked the Plan to pay for 76705. The Plan denied your request. The Plan says this is a bundled code.

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 76705 has a bundled relationship with code 93976 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 the services (76705) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 7, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges. 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 $5 copayment for primary care provider visits. The medical records show that you had an office visit on October 7, 2020. Therefore, you are responsible to pay the $5 copayment.
You have been asked to pay a $5 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex-C.
You asked the Plan to pre-approve Gamunex-C. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not covered under the enrollee's medical benefit.
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 Gamunex-C.
Benefits for Gamunex-C 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on April 20, 2021.
You asked the Plan to pay for the full mouth debridement. You say that you asked your dentist to only provide services that are covered. You also say that you do not believe you had a debridement, but only a simple cleaning. The Plan denied your request. The Plan says your plan does not cover this procedure.
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 full mouth debridement (D4355) provided on April 20, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery with interspinous process distraction device.

You asked the Plan to pre-approve spine surgery with interspinous process distraction device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 pre-approve spine surgery with interspinous process distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process spacer devices remain experimental. More research is needed to show safety and efficacy of these devices. Therefore, the enrollee does not meet criteria for the requested 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 spine surgery with interspinous process distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve spine surgery with interspinous process distraction device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nonemergency transport taxi (A0100) beyond the Plan's 6-trip limit.

You asked the Plan to pre-approve additional routine transport beyond the Plan's trip limit. You say that you need transportation to necessary appointments. The Plan denied your request. The Plan says you have exceeded your maximum number of trips for the year and therefore additional trips are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 6 trips per year.

We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that 6 routine transportation trips have already been covered in the year 2021. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve nonemergency transport taxi (A0100) beyond the Plan's 6-trip limit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection testing provided to the enrollee on
February 15, 2021.
You asked the Plan to pay for the testing. You say that there were two completely different tests for the purpose
of two different results. The Plan denied your request. The Plan says these services are not authorized because
predictive screening testing is not a Medicare benefit.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the review indicates that the services are not covered because predictive screening testing is not a
Medicare benefit. There was no specific clinical rationale for the obtained laboratory studies.
The review has determined that the infectious agent detection testing provided to the enrollee on February 15,
2021 was not 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 infectious agent detection testing provided to the enrollee on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on October 12, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received from an out-of-network
provider on August 20, 2020.

You asked the Plan to waive the coinsurance for the out-of-network lab services. You say that the provider told
you that they were not going to submit anything to your insurance. You said that you should not owe anything.
The Plan denied your request. The Plan says you were charged this coinsurance 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 50%
coinsurance for out-of-network lab services.

You have been asked to pay 50% coinsurance for the out-of-network lab services. Both the lab that provided
these services and the ordering provider is out-of-network with the plan, so these lab services fall within the
out-of-network lab 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 coinsurance for lab
services you received from an out-of-network provider on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999), two porcelain/ceramic pontics (D6245), three porcelain/ceramic retainer crowns (D6740) and an extraction (D7140) provided on May 24, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says unspecified preventative procedures, pontics and retainer crowns are not covered by your dental benefit. The extraction is a covered service, however there is a limit of one extraction per year. You had two extractions on the date in question, and one of these was covered by the Plan, however the second extraction exceeds what is covered by your dental 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. The Plan can cover certain preventative and comprehensive supplemental dental services that are outlined in the contract. The Plan can cover a maximum of one extraction per year.
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 or are requested in a frequency that exceeds what is covered by this benefit. Documentation shows that you had two extractions on the date in question, once of which was covered by the Plan.
The second extraction exceeds the Plan's maximum number of extraction procedures for the benefit period, and the remaining services are not covered by the benefit.
Therefore, we decided that the Plan does not have to pay for an unspecified preventative procedure (D1999), two porcelain/ceramic pontics (D6245), three porcelain/ceramic retainer crowns (D6740) and an extraction (D7140) provided on May 24, 2021.