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

We decided that the Plan does not have to pay for three dimensional (3D) rendering with interpretation and
reporting of computed tomography (CT) (code 76377-26).
You asked the Plan to pay for 3D rendering. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because the provider did not submit
records to support a second unit of this code.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient
information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. You did not submit medical records to support the service as it has
been billed on this claim. The Plan requested supporting records, but none were submitted. Without supporting
records, you have not furnished sufficient information to justify payment for this service as it has been billed.
Based on this information, we decided that Medicare rules for coverage of 3D rendering have not been met.
Therefore, we decided that the Plan does not have to pay for three dimensional (3D) rendering with
interpretation and reporting of computed tomography (CT) (code 76377-26).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on January 6, 2021.

You asked the Plan to pay for the core buildup. You say that there is no way your benefit could be exhausted because the insurance coverage began on January 1, 2021. The Plan denied your request. The Plan says your benefit had been exhausted.

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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the January 6, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0483) rendered by the out-of-network (OON) provider on August 3, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0483) rendered by the out-of-network (OON) provider on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services received on April 16, 2021.

You asked the Plan to pay for the services. You say that you were due for the shot. The Plan denied your request. The Plan says the vaccine and its administration are both not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization services received on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure A4550) provided to the enrollee on May 23, 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 this is not reimbursable as a separate charge.

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 A4550 is a column II code to column I code 20610. This claim has not been billed with an appropriate 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 surgical services (procedure A4550) provided to the enrollee on May 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from April 26, 2021, through May 3, 2021.
You asked the Plan to pay for inpatient hospital services. The Plan denied your request. The Plan says there is a third-party liability claim open on this claim with another insurance company. As a Medicare plan, Medicare is the payor of last resort. Claims should be billed to the other liability carrier and then billed to the Plan as secondary.
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 hospital services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided from April 26, 2021, through May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Hyalgan. Our reviewer says that the requirements for coverage of Hyalgan have not been met. Our physician reviewer found the Plan requires a trial of Euflexxa and Synvisc-One before they will approve the requested drug. The records provided do not show that the enrollee has tried these drugs or that these drugs would likely be less effective or have adverse effects.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
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 July 12, 2021.
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 July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the residual tooth root removal (D7250) provided on August 19, 2021.
You asked the Plan to pay for the residual tooth root removal (D7250). You say that it was the doctor's decision to use nitrous oxide and the tooth root removal was a medical procedure. You say that you are appealing the denial. The Plan denied your request. The Plan says the nitrous oxide (D9230) will be reprocessed for payment and the residual tooth roots removal (D7250) is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the residual tooth root removal (D7250) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the residual tooth root removal (D7250) provided on August 19, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Afirma testing (81545) provided on October 27, 2020.

You asked the Plan to pay for Afirma testing. You say that this is a covered service. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that Afirma services are covered for patients with one or more thyroid nodules with a history or characteristics suggesting malignancy. 

We looked at the file and Medicare rules. The submitted medical records do not document a history or characteristic suggesting malignancy as described in the rules section.

Based on this information, we decided that Medicare rules for coverage of Afirma testing have not been met. Therefore, we decided that the Plan does not have to pay for Afirma testing (81545) provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 21, 2021.
You asked the Plan to pay for the referral. You say that this should be paid for. The Plan denied your request.
The Plan says an approved referral from the primary care physician is needed.
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 laboratory services provided to the enrollee on July 21, 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 July 20, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not owe anything. 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 primary care physician visits. The medical records show that you received services beyond an annual wellness exam on July 20, 2021. Therefore, you are responsible to pay the $10 copayment.
You have been asked to pay a $10 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 July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the anesthesia (01380) rendered by the out-of-network (OON) provider on January 20, 2021.
You asked the Plan to issue reimbursement 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 issue reimbursement for this service. Therefore, we decided that the Plan does not have to issue reimbursement for the anesthesia (01380) rendered by the out-of-network (OON) provider on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted clinical information does not include imaging results nor document failure of non-surgical, non-injection care.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no submitted imaging report or documentation of physical therapy having been tried. 

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 pre-approve a lumbar epidural steroid injection for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (81404, 81442, and 81479) provided on June 1,
2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the
laboratory services (81404, 81442, and 81479) provided on June 1, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is recovering from a recent fall and the lack of rehabilitation will harm her. The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of a tibial plateau fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the anti-reflective coating provided on August 6, 2021.
You asked the Plan to fully pay for the anti-reflective coating. You say that he has full coverage which includes vision care that is in good standing. You say that he has plenty of insurance left and payment should be covered. The Plan denied your request. The Plan says the $350 eyewear allowance was exhausted with this purchase.
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 up to $350 every calendar year for eyewear. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the anti-reflective coating have not been met. Specifically, the Plan paid $350 toward the eyewear purchased on August 6, 2021. The member is responsible for any amount over the $350 allowance. Therefore, we decided that the Plan does not have to fully pay for the anti-reflective coating provided on August 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy provided on June 9, 2021.
You asked the Plan to pay for the home infusion therapy. You say that the patient was serviced in good faith and the provider should be reimbursed accordingly. You say that the claim should be reprocessed for correct payment. The Plan denied your request. The Plan says the code is not valid for Medicare billing purposes.
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 S9338 is home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9338 is not supported in the medical record. Specifically, CPT code S9338 has a status indicator of I. This means that CPT code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy provided on June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.