Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy pump, purchased on May 22, 2021, through June 15, 2021.  You asked the Plan to waive the coinsurance for the negative pressure wound therapy pump. You say that there should not be a coinsurance. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Medicare covered items with a total rental or purchase price of $350.01 or more of the Medicare allowable rate per item for durable medical equipment (DME) and related supplies.   The enrollee has been asked to pay a 20% coinsurance for the negative pressure wound therapy pump. This item falls within the durable medical equipment (DME) and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy pump, purchased on May 22, 2021, through June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bandages and burn cream (A9270), purchases on July 28, 2021.  

You asked the Plan to pay for the bandages and burn cream. You say that the items were medically necessary. The Plan denied your request. The Plan says you did not obtain durable medical equipment (DME) supplies from a DME provider, but instead purchased the supplies from a retail store that does not participate with Medicare.  

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the bandages and burn cream (A9270), purchases on July 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolonged services (99354) provided on July 19, 2021.  You asked the Plan to pay for the prolonged services (99354). You say that the records for this visit substantiate the prolonged code and this should be paid. The Plan denied your request. The Plan says an edit exists between 90833 and 99354 and no modifiers are allowed with this code pair.  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 99354 is a column II code to column I code 90833. This claim cannot be billed with a modifier to bypass the edit. 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 prolonged services (99354) provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on August 23, 2021  

You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that cancer designation is necessary as your mother died of mouth cancer, which was possibly a pre-existing condition. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on August 23, 2021
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the allograft (20930) provided on May 13, 2021.  

You asked the Plan to pay for the allograft (20930). You say that medical providers must render treatment when they are needed, and this treatment complies with the policy terms regarding medical necessity. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  

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 20930 is allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure).     

We find that CPT code 20930 is not supported in the medical record. Specifically, CPT code 20930 has a status indicator of B. This means that CPT code 20930 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the allograft (20930) have not been met. Therefore, we decided that the Plan does not have to pay for the allograft (20930) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office visits. You say that you were seen by the requested providers during your admission at the hospital. You also say you were given the devastating news that you have pancreatic cancer, and you were able to establish a rapport with both of these providers. The Plan denied your request. The Plan says the doctor you requested is not a provider for your medical group or any of the Plan's medical groups. The Plan also says that they determined that a network provider can care for your medical problem.  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 provider at issue in this case is not a network provider with the Plan. 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 office visits. Our reviewer says that this appeal request does not meet the criteria. Our physician reviewer found the patient can safely be treated by an in-network provider.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visits have not been met.   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 office visits. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided from August 25, 2021, to September 2, 2021.  

You asked the Plan to pay for the services provided. You say that your plan covers 10 chiropractic visits per year. The Plan denied your request. The Plan says the services provided 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 file shows that you received extraspinal chiropractic manipulative treatment. This service is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from August 25, 2021, to September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 29, 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 standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity.  

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the Medicare criteria for the urinary PCR panel. The standard of care for the evaluation of urinary urgency with cognitive symptoms would be performance of a urinalysis with urine culture and sensitivity, not a urinary PCR test.  

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for vision care provided from January 4, 2021, to September 9, 2021.  You asked the Plan to waive the copayments for vision care. You say that you should receive one routine eye exam per year. 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 $0 copayment for routine eye exams and a $20 copayment for specialist visits for vision care.   The medical records show that you received diagnostic vision care from January 4, 2021, to September 9, 2021, for a total of 3 visits. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 3 (vision care visits) = $60.   You have been asked to pay the total copayment amount of $60 for vision care. Vision care falls within the vision care 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 vision care provided from January 4, 2021, to September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on January 18, 2021.  You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim has not been billed in accordance with Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that a PC/TC indicator of 3 represents TC only codes.   We looked at the file and Medicare rules. In this case, the billed procedure code 99153 has a PC/TC indicator of 3 which represents a TC only code with no PC payment. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.    Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the clear plugged Eyelid Gland service, provided on February 3, 2021.  You asked the Plan to pay for the clear plugged Eyelid Gland service. You say that the service should be covered. The Plan denied your request. The Plan says this is not covered.  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. Before you receive services from an ophthalmologist for diagnosis and/or treatment of a medical condition of the eye, you must first obtain a referral from your PCP.  We looked at the file and the Plan's rules. You did not obtain a referral for this service. Based on this information, we decided that the Plan's rules for coverage of the clear plugged Eyelid Gland service have not been met. Therefore, we decided that the Plan does not have to pay for the clear plugged Eyelid Gland service, provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on July 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and the provider did not know that the facility failed to get prior authorization for the enrollee. The Plan denied your request. The Plan says no prior authorization was obtained.  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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 16, 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 the hospital services provided on February 21, 2021 to February 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the hospital services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 hospital services provided on February 21, 2021 to February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory tests provided on September 15, 2021.  You asked the Plan to waive the copayment for laboratory tests. You say that you were not aware that you owed a copayment for laboratory tests. You state that you received the services during an annual wellness exam. 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 laboratory tests.  You received laboratory tests on September 15, 2021. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment.      You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory tests provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on May 11, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.  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 targeted genomic sequence analysis panel 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 targeted genomic sequence analysis panel provided on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 26, 2020.  

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.  

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on July 7, 2021.  You asked the Plan to pay for the GeneSight Psychotropic test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.    The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code identifier should be entered adjacent to the CPT code in the comment/narrative field.  We looked at the file and Medicare rules. Review of the file shows that the claim did not include the required Z code. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic test have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on July 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on March 2, 2021.  You asked the Plan to pay for the outpatient office visit. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing provided on June 7, 2021.  You asked the Plan to pay for the FISH testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 FISH testing 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 fluorescence in situ hybridization (FISH) testing provided on June 7, 2021.