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

 We decided that the Plan does not have to waive the copayment for specialist services provided on June 25, 2021.  You asked the Plan to waive the copayment for specialist services. You say that the charges are fraudulent because you did not receive any services on this day. 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 $40 copayment for specialist services.   The medica records show that you received specialist services on June 25, 2021. Therefore, you are responsible to pay the $40 copayment.   You have been asked to pay a $40 copayment for specialist services. Specialist services fall 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 specialist services provided on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code 81408, 81406, 81405, 81407) provided to the enrollee on September 22, 2020, by an out-of-network provider.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider and the servicing laboratory does not participate with this health plan.  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 laboratory services (CPT code 81408, 81406, 81405, 81407) provided to the enrollee on September 22, 2020, by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telehealth office services (CPT code 99213-95) provided to the enrollee on September 20, 2021.  You asked the Plan to pay for the telehealth office services. You say that the claim should be paid. The Plan denied your request. The Plan says the service is 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.  Telehealth services must be submitted to include the place of service equal to what it would have been had the service been furnished in person and append modifier 95 to indicate the service took place via telehealth. According to the service billed, the place of service listed was '02-Telehealth Provided Other than in Patient's Home'. Based on this information, we decided that Medicare rules for coverage of the telehealth office services have not been met. Therefore, we decided that the Plan does not have to pay for the telehealth office services (CPT code 99213-95) provided to the enrollee on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided October 22, 2021.  You asked the Plan to pay for the prefabricated post and core. You say that when you signed up for your plan you requested to have all dental services covered. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 prefabricated post and core in addition to crown (D2954) provided October 22, 2021.   Your complaint about not having coverage for comprehensive dental services 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visits rendered on April 21, 2021 to May 27, 2021.  You asked the Plan to pay for these services. You say that you have a PPO plan and out-of-network coverage. The Plan denied your request. The Plan says the provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visits rendered on April 21, 2021 to May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).  You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the documentation states that the member has undergone a trial using Flexitouch to ensure fit but does not include documentation that the member completed the four-week trial of E0650 or E0651 as required.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve FoundationOne CDx testing.  You asked the Plan to pre-approve FoundationOne CDx testing. You say that your oncologist wants this test done so you can move forward with treatment. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the documentation does not support that you have the presence of a covered type of cancer.  The Plan follows Medicare rules. Medicare rules state that Next Generation Sequencing (NGS) testing such as FoundationOne CDx panel may be covered under certain circumstances.   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 FoundationOne CDx testing. Our reviewer says that you do not meet the Medicare criteria for this testing. Our physician reviewer found the indications for FoundationOne CDx genetic testing include non-small cell lung cancer, melanoma, breast cancer, colorectal cancer, ovarian cancer, cholangiocarcinoma, prostate cancer, and solid tumors. You do not have a Food & Drug Administration (FDA) approved or FDA-cleared indication for use in your type of cancer.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FoundationOne CDx testing have not been met. Therefore, we decided that the Plan does not have to pre-approve FoundationOne CDx testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0239U
provided on July 27, 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 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 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 coded 0239U provided on July 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transvaginal ultrasound provided on August 25, 2021.  You asked the Plan to pay for the transvaginal ultrasound. 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 76830 is ultrasound, transvaginal.  We find that CPT code 76830 is not supported in the medical record. Specifically, the documentation shows that the enrollee is a transgender enrollee. The enrollee was born a female and still has all of the female organs. Condition code "45" should be used if the enrollee is transgender. This condition code was not billed with this service. Based on this information, we decided that Medicare rules for coverage of the transvaginal ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the transvaginal ultrasound provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0482) provided on March 10, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on March 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 4, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 78-year-old female who was transported via ambulance for a non-emergent trip home for continuation of care following bilateral humerus fractures. She was able to sit in a chair without assistance. The enrollee's vitals were stable and physical was unremarkable. The enrollee was transported without treatment or incident. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport on was medically reasonable and 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the group one power operated vehicle (POV) (K0800).  You asked the Plan to pre-approve the group one power operated vehicle. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 group one power operated vehicle. Our reviewer says that the item is not medically necessary. Our physician reviewer found you are able to ambulate with the use of a walker and there is no documentation indicating the POV will significantly improve your ability to participate in MRADLs. Additionally, the documentation does not reveal a detailed home assessment indicating that the home has adequate space for maneuvering the requested K0800 scooter.  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 group one power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve the group one power operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to pay for CPT 00537. We decided that the Plan does not have to pay for CPT 99100.   You asked the Plan to pay for the services. The Plan says that the services are not payable.  We decided that the Plan has to pay for CPT 00537.   The Plan follows 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 00537 is "Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation".  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 use of code 00537 is supported by the records provided. Our physician reviewer found that the documentation states an "Ablation atrial flutter and Loop recorder" implantation was performed. If this is the procedure performed, CPT 00537 would be reported in this case.   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 been met. Therefore, we decided that the Plan has to pay for CPT 00537.   We also decided that the Plan does not have to pay for CPT 99100.  The Plan follows Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99100). 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 CPT 99100.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 16, 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 genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary.  

We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bridge.

You asked the Plan to pre-approve the requested services. You say that you are not able to eat properly. The Plan denied your request. The Plan says the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The file shows that a dental bridge (pontics and retainer crowns) were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental bridge.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower, less intensive 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and coronavirus infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the laminotomy (partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower or lumbar spine) (CPT code 63030), for the enrollee.  You asked the Plan to pre-approve the service. You say that the surgery is necessary. The Plan denied your request. The Plan says this surgery is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative measures to include recent physical therapy (PT) for lower back pain (LBP).  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the laminotomy (partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower or lumbar spine) (CPT code 63030), for the enrollee.