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

We decided that the Plan does not have to pay for lab services (81455) provided May 3, 2021.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says this procedure is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing with procedure code 81455 is unlikely to impact decision making in clinical management and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The procedure code billed is not covered. 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 (81455) provided May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a neurologist on June 28, 2021.
You asked the Plan to waive the copayment for the neurology visit. You say that you just had a short conversation with the doctor and you think the charges are too high. 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 $15 copayment for visits or consultations with a specialist. You have been asked to pay a $15 copayment for the neurology visit. This copayment applies regardless of how long the visit lasts. 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 the office visit you had with a neurologist on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided on December 5, 2019.
You asked the Plan to pay for therapy services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that he services of an Occupational Therapy Assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. The record shows that the service at issue was provided by an OTA and billed by a Nurse Practitioner, as incident to the practitioner's service. Based on this information, we
decided that Medicare rules for coverage of therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided on December 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 25, 2021, to June 5, 2021.
You asked the Plan to pay for the SNF care provided from May 25, 2021, to June 5, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services after May 24, 2021. The Plan also says that the services could have been provided at a lower level of care.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from May 25, 2021, to June 5, 2021, have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 25, 2021, to June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of a drug or substance under the skin or into the muscle (96372) provided on July 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an injection. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an OON 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 injection of a drug or substance under the skin or into the muscle (96372) provided on July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on May 3, 2021.
You asked the Plan to pay for the ambulance service. You say that you were afraid you were having a heart attack. You say that the paramedics would not allow your wife to ride in the ambulance with you due to the coronavirus. You also say that you decided to have your wife drive you to the hospital instead. The Plan denied your request. The Plan says transport was not provided. The Plan also says that ambulance response without transport is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided on May 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on February 11, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you do not want to pay this copayment when you had to drive 108 miles for this service. 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 $20 copayment for ultrasounds. You have been asked to pay a $20 copayment for the ultrasound. 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 the ultrasound you had on February 11, 2021.
Your complaint about the Plan's patient financial assistance program is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray of the chest (71045) billed with the -77 modifier provided on April 22, 2021.
You asked the Plan to pay for the X-ray of the chest. You say that you would like this claim reprocessed based on the documentation provided. The Plan denied your request. The Plan says the claim has 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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, this code has been billed with the -77 modifier which is used to report a repeat procedure by another physician. However, this claim was billed twice by the same provider not another physician.
Based on this information, we decided that Medicare rules for coverage of the X-ray of the chest have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray of the chest (71045) billed with the -77 modifier provided on April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have skilled nursing or therapy needs that need to be provided in an inpatient setting on a daily basis.
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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a minimal to contact guard assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation for sacroiliac (SI) joint pain provided on March 4, 2021.
You asked the Plan to pay for the radiofrequency ablation for SI joint pain. You say that these services were medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 radiofrequency ablation for SI joint pain. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation (RFA) for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested SI joint RFA 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 the radiofrequency ablation for SI joint pain have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation for sacroiliac (SI) joint pain provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 4, 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 services are 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 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 laboratory services rendered on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on April 21, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary
diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the abdomen (74018) provided on July 16, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for an x-ray of the abdomen. You say that the services were medically necessary, and you would like review for payment on this claim. The Plan denied your request. The Plan says services were provided by an OON 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 x-ray of the abdomen (74018) provided on July 16, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for remote monitoring of a wireless pulmonary artery pressure sensor provided on June 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for remote monitoring. 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 remote monitoring of a wireless pulmonary artery pressure sensor provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that this is the only thing that helps your
condition. The Plan denied your request. The Plan says you do not require a therapist for treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional services. Our physician
reviewer found that the additional requested therapy is not generally accepted as effective therapy for your
condition beyond what was approved by the Plan. You have had prior therapy of 14 outpatient visits.
The records do not demonstrate that the ongoing skills of a professional therapist are required to provide
treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. The
requested services are not part of a maintenance program. The skill of a qualified therapist is not required to
deliver a program to maintain your current condition or to prevent/slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82785, 36415, 85025, 86609, 86360, 86359, 86357, 83520, 86355, 82787, 82784, 86606, 86001, 86003) provided on February 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that the referring provider did not get an authorization over to the Plan for diagnostic testing. You also say it was the provider's responsibility to get an authorization to the Plan. You now have a bill that you cannot afford to pay. The Plan denied your request. The Plan says services were provided by an OON 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 records provided for review also show that the enrollee was referred by a non-participating provider. 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 laboratory services (82785, 36415, 85025, 86609, 86360, 86359, 86357, 83520, 86355, 82787, 82784, 86606, 86001, 86003) provided on February 17, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two cataract surgeries you had on
May 5, 2021, and May 12, 2021.
You asked the Plan to waive the copayments for the two cataract surgeries. You say that you feel as though this copayment is too high for a senior on a fixed income. The Plan denied your request. The Plan says you were charged these 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 $395 copayment per visit for outpatient surgery. You have been asked to pay a $395 copayment per visit for the two cataract surgeries. The two cataract surgeries fall within the outpatient surgery 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 the two cataract surgeries you had on May 5, 2021, and May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on May 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that these services were medically reasonable and necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 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 office visit (99213) provided on May 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 Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G1-V7 provided from February 2, 2021, through February 27, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed as you argue they were billed correctly. The Plan denied your request. The Plan says these claims require revisions before they can be paid.
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 90999 is unlisted dialysis procedure, inpatient or outpatient. The CPT Code Manual definition of code J0604 is cinacalcet, oral, 1 mg, (for end stage renal disease on dialysis). We find that CPT codes J0604 and 90999 is not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G1-V7 provided from February 2, 2021, through February 27, 2021.