Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the respiratory pathogen panel testing (0241U) provided on May 14, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this service is not covered.
The Plan follows Medicare rules. Medicare rules say that respiratory pathogen panel testing is covered for the indications established in the applicable LCD. 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 testing. Our reviewer says that the requested testing is medically reasonable and necessary. Our physician reviewer found that the enrollee received services for worsening SOB, that was constant and with tightness and slight cough, which was likely pulmonary venous congestion. The review has determined that the requested testing (0241U) medically reasonable and necessary according to the coverage criteria established in the LCD. 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 testing have been met. Therefore, we decided that the Plan has to pay for the respiratory pathogen panel testing (0241U) provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 2, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on May 7, 2021, by an OON
provider.
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 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 services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the pathology services provided on May 7, 2021, by an OON
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray provided on June 7, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this code is not separately payable.
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 73560 was billed with code 73562. We looked at the file and the rules. Code 73560 is payable when billed with a modifier. The records do not show the service at issue was billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the knee x-ray provided on June 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on March 11, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.
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 physical therapy services. 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 physical therapy services provided on
March 11, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on December 22, 2020.
You asked the Plan to pay for genetic testing. You say that the enrollee meets the requirements for this testing which has been determined to be reasonable and necessary for management of the enrollee's condition. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made for this testing constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
April 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the
enrollee on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the procedure to declot a central venous catheter you had at an outpatient hospital facility on January 6, 2021.
You asked the Plan to waive the copayment for the declotting procedure. You say that you are going through chemotherapy and you have to have your port flushed out every six weeks. You do not believe this should be considered surgery as it takes less than ten minutes. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($293.97) is less than your copayment obligation, you are responsible for the full allowed 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 $345 copayment for surgery or other services at an outpatient hospital facility.
You have been asked to pay a $345 copayment for the declotting procedure. The declotting procedure falls within the surgery or other services at an outpatient hospital facility benefit category. The medical records confirm that the facility where you received these services is considered an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the procedure to declot a central venous catheter you had at an outpatient hospital facility on January 6, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 12, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you do not agree with the denial of these services. You say that you had no choice but to find a new dentist as yours had retired. You also say that you feel these services should be covered. The Plan denied your request. The Plan says 1 complete series or panoramic x-ray is covered every 5 years. The Plan also says that the frequency limit has been exceeded.
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 and the services are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the complete series x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says the rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 64-year-old male with coronavirus infection, aortic stenosis, rhabdomyolysis and acute kidney injury. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs provided from April 20, 2021, to April 21, 2021.
You asked the Plan to pay for the services provided. You say that they used the wrong code in billing. The Plan denied your request. The Plan says you can submit the claim to your drug plan for reimbursement.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.
The file shows that you were provided acetaminophen, ibuprofen, and potassium chloride while receiving
outpatient hospital services. The provided drugs are not among the types which are covered by Medicare Part B
during outpatient care. Therefore, we decided that the Plan does not have to pay for the drugs provided from
April 20, 2021, to April 21, 2021.
Benefits for the services provided may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 23, 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 provided on March 23, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, basic life support, emergency transport provided on May 3, 2021.
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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, emergency transport. Our reviewer says that the ambulance transport was medically necessary. Our physician reviewer found that the record indicates that the enrollee suffered a fall and was unable to bear weight. The enrollee has a dense expressive aphasia from previous stroke. A prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. The elements of the coverage criteria are satisfied. The requested service is recommended. 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, emergency transport have been met. Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) for teeth # 8 and 13, abutment supported crown (D6060) for tooth # 8, a crown (D2751) for teeth # 4 and 12, and implants (D6010) for teeth # 8 and 13.
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says the crowns for teeth # 4 and 12 are not medically necessary. The Plan says that implants are not covered when there is more than 1 tooth missing in the arch. The Plan also says that the prefabricated abutment and abutment supported crown are not covered as the treatment related to this service is not approved.
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 Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says
that the implants and crowns are not medically necessary. Our physician reviewer found there are more than 1 tooth missing in the upper arch. The reviewer found that implants are not covered when more than 1 tooth is missing in an arch. Therefore, the implants are not medically reasonable or necessary. The reviewer found that the crown on tooth # 12 is not in need of repair or replacement. The reviewer found that tooth # 4 has an existing one surface restoration and does not appear to have any significant breakdown. Therefore, the reviewer found that the crowns are not medically reasonable or necessary either. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows you are missing more than 1 tooth in the upper arch. The file also shows that the teeth # 4 and 12 do not have significant breakdown that would warrant new crowns. Therefore, we decided that the Plan does not have to pre-approve prefabricated abutments (D6056) for teeth # 8 and 13, abutment supported crown (D6060) for tooth # 8, a crown (D2751) for teeth # 4 and 12, and implants (D6010) for teeth # 8 and 13.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from December 25, 2020 to December 30, 2020.
You asked the Plan to pay for the inpatient hospital 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, Medicare guidance says that diagnosis code Z88.2 is present on the exempt from reporting list; however, the claim submitted has listed the POA as "N". Therefore,
we decided that the Plan does not have to pay for the inpatient hospital services provided from December 25, 2020 to December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on February 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim originally denied for not meeting Medicare NCD/LCD criteria, but the service is not authorized.
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. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on February 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), surgical extraction (D7210), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on January 21, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the problem focused limited oral evaluation, surgical extraction, and deep sedation/general anesthesia. You say that there is no overpayment because you paid the amount that was reimbursed to you by the Plan. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective April 1, 2008, to April 1, 2022.
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 covered when they are received by a provider who has opted out of Medicare. The record shows that that you signed a private contract with the opted out provider which clearly states that you understood that . Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), surgical extraction (D7210), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on January 21, 2021 by a Medicare opt out provider.
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 you were in the hospital due to Coronavirus, and you are having trouble breathing. You also say that your oxygen levels are low, and the hospital recommends you go to the IRF to recover. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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. 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