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

 We decided that the Plan has to pay for genetic testing provided on August 26, 2020.  You asked the Plan to pay for genetic testing. You say that the ordering physician attested that coverage criteria were met for this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not ordered/approved by the ordering physician according to the Plan's outreach attempt.  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.  This testing was ordered by an in-network physician. The file does not show that the plan provided notice that genetic testing would not be covered. Although the Plan states that this testing was not ordered/approved by the ordering physician, the records submitted include a signed lab order from the in-network treating physician for the specific testing billed on this claim. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on August 26, 2020.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia service (99100) provided on July 16, 2021.  You asked the Plan to pay for anesthesia. You say that this claim was coded correctly. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment and is not separately payable.   We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 24, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from November 24, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from November 24, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 24, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond November 24, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 24, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 24, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an office visit provided on May 28, 2021.  You asked the Plan to waive the coinsurance for an office visit. You say that you did not see the physician listed on the statement and saw another provider in regards to transitional care. 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 20% coinsurance for physician/practitioner services, including doctor's office visits.   The medical records show that you had an office visit on May 28, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $214.35 and 20% of that is $42.87.   You have been asked to pay the total coinsurance amount of $42.87 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 coinsurance for an office visit provided on May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiation services (procedure code 77263) provided to the enrollee on February 12, 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 code is not recognized by the Outpatient Prospective Payment System (OPPS).  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 77263 is "Therapeutic radiology treatment planning; complex."  We find that CPT code 77263 is not supported in the medical record. Specifically, this code is not recognized as being able to be used by Medicare and paid for. 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 radiation services (procedure code 77263) provided to the enrollee on February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 17, 2021.  You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because you are a new patient and an ovarian cancer survivor. 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 $160 copayment for ultrasounds.   You have been asked to pay a $160 copayment for an ultrasound. An ultrasound 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 ultrasound provided on June 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 3, 2021.  You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.  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 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 subsequent nursing facility care provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the personal protective equipment (D1999 x 2), administration of nitrous oxide (D9230), and the free soft tissue graft procedure (D4277) provided from March 23, 2021, to April 8, 2021.  You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that a gum graft was a medical procedure and not a dental procedure. You also say that you would like this to be reprocessed as a medical claim. The Plan denied your request. The Plan says personal protective equipment are not listed as covered services. The Plan says that free soft tissue graft procedures is not listed as a covered service either. The Plan says that nitrous oxide is only covered when performed in conjunction with other covered services. The Plan also says that this claim was sent to the medical claims team for processing.  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 dental services are not among those covered under this benefit. Additionally, the record shows that this claim was sent to the medical claims team for further review. Therefore, we decided that the Plan does not have to pay for the personal protective equipment (D1999 x 2), administration of nitrous oxide (D9230), and the free soft tissue graft procedure (D4277) provided from March 23, 2021, to April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences (75561) rendered by the out-of-network (OON) provider on April 6, 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 cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences (75561) rendered by the out-of-network (OON) provider on April 6, 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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.    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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. While the enrollee may require physical and/or occupational therapy, there is no documented need for an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the dental services provided from February 19, 2021 through May 6, 2021.  You asked the Plan to pay more for the dental services. You say that you were told they couldn't do the amount of work required and you needed to seek services of a specialist. You say that all the information required is available to process the claim. The Plan denied your request. The Plan says additional benefits up to your $2,000 maximum have been approved. The Plan also says that once the calendar year maximum is met, no additional benefits are available.  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, you also have an annual maximum of $2,000 toward covered dental services per calendar year. The Plan already issued $2,000 for dental services in the 2021 plan year, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the dental services provided from February 19, 2021 through May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection of a major joint or bursa; without ultrasound guidance (20610), the office visit (99203), and the methylprednisolone acetate injection (J1040) rendered by the out-of-network (OON) provider on July 6, 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 arthrocentesis, aspiration and/or injection of a major joint or bursa; without ultrasound guidance (20610), the office visit (99203), and the methylprednisolone acetate injection (J1040) rendered by the out-of-network (OON) provider on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99213) and chiropractic manipulative treatment (98941) provided on July 1, 2020 to July 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that please see all medical records as you were told this needs preauthorization. You were also told by another representative that a preauthorization was not needed. Please review and reprocess these claims. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 outpatient office visit (99213) and chiropractic manipulative treatment (98941) provided on July 1, 2020 to July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nayzilam spray, 5 mg.  You asked the Plan to pre-approve Nayzilam spray. You say that this drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nayzilam spray, 5 mg.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the retroperitoneal ultrasound you had on November 6, 2020.  You asked the Plan to waive the coinsurance for the retroperitoneal ultrasound. You did not provide an argument with your appeal request. The Plan denied your request. The Plan's case file did not specifically address the ultrasound service that is in dispute. Their rationale applied to another service that was not the subject of this appeal.  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 20% coinsurance for diagnostic tests and radiological services.   You have been asked to pay 20% coinsurance for the retroperitoneal ultrasound. The retroperitoneal ultrasound falls within the diagnostic tests and radiological services 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 coinsurance for the retroperitoneal ultrasound you had on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic mammogram with breast tomosynthesis you had on June 15, 2021.  You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you have never had a copayment for a mammogram before.  You said that this was your yearly mammogram. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that this mammogram was ordered by your doctor as a six-month follow-up diagnostic mammogram due to an area of concern in the right breast identified during a prior mammogram on December 14, 2020.  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 basic imaging services.      You have been asked to pay a $10 copayment for the diagnostic mammogram. Your doctor was called to confirm that the mammogram you had was not a yearly screening mammogram, but a diagnostic one to evaluate your right breast. That is why the diagnostic mammogram falls within the basic imaging services 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 the diagnostic mammogram with breast tomosynthesis you had on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0480, 80307) rendered by the out-of-network (OON) provider on February 23, 2021.  You asked the Plan to pay for the 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 (G0480, 80307) rendered by the out-of-network (OON) provider on February 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Basaglar injection, 100 units.  You asked the Plan to pre-approve Basaglar injection. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Basaglar injection, 100 units.   Benefits for Basaglar injection may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.