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

We decided that the Plan does not have to waive the copayment for wound care services (97597, 97605) provided April 5, 2021 to May 7, 2021.

You asked the Plan to waive the copayment for the wound care services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 for Outpatient Surgery services. 

You have been asked to pay the Medicare allowable amount of $173 per visit, for 14 visits (a total of $2,422) for the wound care services. The wound care services fall within the Outpatient Surgery services benefit category.

The $173 allowable amount is less than the $395 per-visit copayment listed in the Evidence of Coverage. 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 wound care services (97597, 97605) provided April 5, 2021 to May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Genesight Psychotropic assay provided on September 10, 2020.

You asked the Plan to pay for the Genesight assay. You say that this is a covered test which should be paid. The Plan denied your request. The Plan says payment cannot be made for this test because the provider is listed in a database for providers who have been terminated for cause.

The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx testing, such as Genesight Psychotropic, is not supported by high-quality evidence at this time. Therefore, we decided that the Plan does not have to pay for the Genesight Psychotropic assay provided on September 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88321) provided September 24, 2020.

You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The Plan denied your request. The Plan says this claim is a duplicate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 88321 is not supported in the medical record. Specifically, the records provided support one unit of the code billed. Code 88321 was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88321) provided September 24, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the Botox injection provided on May 27, 2020, August 19, 2020 and December 2, 2020.
You asked the Plan to waive the coinsurance for the Botox injections. You say that you were charged $10.99 for all of your appointments and later received a bill for $233.31. You say that you wouldn't have gone forward with the treatments if you were told the cost at the first appointment. The Plan denied your request. The Plan says that the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms how much you should expect to pay for Part B drug injections received in a physician's office. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% coinsurance for the botox injections. The Plan contract does not clearly say how much enrollees must pay for Part B drug injections received in a physician's office. The Plan contract only lists coinsurance for a 30-day supply from a network pharmacy. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for the Botox injection provided on May 27, 2020, August 19, 2020 and December 2, 2020.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs more than one therapeutic discipline and medical complexity. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.

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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services with modifier GZ provided on November 1, 2020.

You asked the Plan to pay for the air ambulance services with modifier GZ. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Medicare says that Plans shall automatically deny claim line(s) items submitted with a GZ modifier. The Plan will accept a corrected claim for review. Therefore, we decided that the Plan does not have to pay for the air ambulance services with modifier GZ provided on November 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code
70450 provided on May 28, 2021.

You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 70450
has a bundled relationship with code 70496 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 computed tomography (CT) scan represented by code 70450 provided
on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services (97530) provided on April 29, 2021.

You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that the services of an OT 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. Based on this information, we decided that Medicare rules for
coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner,
and not a licensed therapist. As such, OT services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on
April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (DME) delivery, set up, and/or dispensing service (A9901) purchased March 1, 2021 from a non-participating provider.

You asked the Plan to pay for the DME services. You say that you are appealing with several bills for the cost of CPAP supplies that you have purchased online at the lowest cost that you could find at the time for when you need to order the items. The Plan denied your request. The Plan says this provider is not eligible to 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 durable medical equipment (DME) delivery, set up, and/or dispensing service (A9901) purchased March 1, 2021 from a non-participating provider.
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. You say that stroke patients sometimes take awhile to recover. You say that, given your previous mobility issues, results may not be immediate. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy in an inpatient setting.

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 the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81408, 81407, 81406) provided December 28, 2020.

You asked the Plan to pre-approve the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were ordered for risk assessment purposes and are screening in nature.

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, Cardiovascular risk assessment testing, is being 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 pre-approve genetic testing (81408, 81407, 81406) provided December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided January 8, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (G0483) provided January 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta. 

You asked the Plan to pre-approve Neulasta. You say that the enrollee has neutropenia with infection. The Plan 
denied your request. The Plan says the drug is not being prescribed for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Neulasta. Our physician reviewer found 
that in this case, the enrollee has stage IIIB endometrial cancer and is receiving paclitaxel/carboplatin 
chemotherapy regimen. This regimen is considered low risk for the development of febrile neutropenia. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for additional levels of transforaminal epidural injections (64484) provided on December 15, 2020.

You asked the Plan to pay for additional levels of transforaminal epidural injections. You say that this was billed correctly. The Plan denied your request. The Plan says the billed units are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that 2 units of CPT code 64484 are not supported in the medical record. The medical record only supports 1 unit of CPT code 64484. Based on this information, we decided that Medicare rules for coverage of additional levels of transforaminal epidural injections have not been met. Therefore, we decided that the Plan does not have to pay for additional levels of transforaminal epidural injections (64484) provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided October 28, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. The record does not include an order from the treating physician. The plan has reached out to the provider and no additional documentation was provided. 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 pay for genetic testing (81479) provided October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you were independent before your hospitalization and you want to return to being independent. You state you are eager to participate in the three (3) hours of aggressive rehabilitation that an IRF will offer you and that a nursing home cannot. You state you still require extensive hands on assistance from the nursing and therapy staff at the hospital to get of bed. The Plan denied your request. The Plan says the stay 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 the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.

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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Computed Tomography (CT) scan (70450) provided May 30, 2021.

You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the service billed has a bundled relationship with another service billed and cannot be paid separately.

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 70450 has a bundled relationship with code 70496 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 a Computed Tomography (CT) scan (70450) provided May 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 86580) provided June 22, 2021.

You asked the Plan to pay for the office visit. You say that the services were medically necessary and the health assessment for employment was a separate service. The Plan denied your request. The Plan says the service at issue is non-covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The clinical documentation shows the primary reason for the visit was a pre-employment exam. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214, 86580) provided June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the brain stem (70553) provided on May 12, 2021.

You asked the Plan to waive the copayment for an MRI scan of the brain stem. You say that the procedure at issue is a baseline for patients newly diagnosed with epilepsy. The Plan denied your request. The Plan says the correct copayment was applied.

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 $325 copayment for each day for Medicare-covered diagnostic radiology services that are not ultrasounds. 

You have been asked to pay a $325 copayment for an MRI scan of the brain stem. an MRI scan of the brain stem falls 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 an MRI scan of the brain stem (70553) provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81493) provided on September 15, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized. There were network providers available.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (81493) provided on September 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87798, 87486, 87541, 87581, and 87640) provided on January 26, 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 the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87798, 87486, 87541, 87581, and 87640) provided on January 26, 2021.