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

 We decided that the Plan does not have to pay for an X-Ray examination (73552-26, -LT and -RT) provided on April 11, 2021.  You asked the Plan to pay for X-Ray 73552. You say that this was necessary to ensure that the enrollee was properly treated. The Plan denied your request. The Plan says the denial of payment for these services is correct, because a more appropriate code 73551 should be billed instead.  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 73552 is radiological examination, femur; minimum 2 views.  We asked our coder 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 X-Ray 73552. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the records do not include sufficient documentation to validate that radiological examinations of the femur; minimum 2 views of the left side (LT) and right side (RT) were the procedures performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of X-Ray 73552 have not been met. Therefore, we decided that the Plan does not have to pay for an X-Ray examination (73552-26, -LT and -RT) provided on April 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy (45380) on July 23, 2021.  You asked the Plan to waive the copayment for a colonoscopy. You say that the service should be covered. The Plan denied your request. The Plan says the copayment was 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 clearly says that you must pay a $150 copayment for outpatient surgery.   You have been asked to pay a $150 copayment for a colonoscopy. The service at issue falls within the outpatient surgery 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 a colonoscopy (45380) on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for selective catheter placement represented by code 36215 and angiography services represented by code 75710 billed for date of service June 4, 2021.  You asked the Plan to pay for codes 36215 and 75710. You say that the medical records provided support the need for the services in dispute. The Plan denied your request. The Plan says the codes which remain in dispute are not supported in the documentation provided.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say a provider shall not report multiple CPT codes when a single comprehensive HCPCS/CPT code describes these services.  We asked our coder 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 codes 36215 and 75710. Our reviewer says that the criteria for coverage have not been met. Our reviewer found procedure code 36215-59, a selective catheter placement within the arterial system; for each first order thoracic or brachiocephalic branch, within a vascular family is documented in the operative note submitted for review. However, this procedure is considered inclusive to code 36902, an introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty. Therefore code 36215 cannot be verified. After careful review of the operative report, payment for the requested service code is not substantiated by the clinical documentation in the operative report submitted for review. Procedure code 75710 is not supported by the medical records submitted. The operative report did not include documentation of a unilateral angiography of an extremity, with radiological supervision and interpretation; therefore this code also cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 36215 and 75710 have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement represented by code 36215 and angiography services represented by code 75710 billed for date of service June 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0429) provided on June 18, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not owe this cost because you were not on life support, and you feel this service was reported incorrectly. The Plan denied your request. The Plan says this service is covered, and this claim was processed in accordance with your contract. All Medicare-covered ambulance services provided via ground or water require a $280 copayment per trip.  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 $280 copayment for each covered, one-way ambulance trip via ground or water.   You have been asked to pay a $280 copayment for the ambulance services. This is the correct copayment for both emergent and non-emergent ambulance transportation services provided via ground. 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 ambulance transportation services (A0429) provided on June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray of the chest (71046) provided on March 8, 2021.  You asked the Plan to pay for the X-ray of the chest. You say that the services provided were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this claim has not been billed with a diagnosis that would indicate the services provided were 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 pay for the X-ray of the chest. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.   Our physician reviewer found in this case, the X-ray of the chest was not appropriate based on the American College of Chest Physicians and the American College of Radiology. This medical journal states "In patients at risk for developing lung cancer, screening for lung cancer with [chest x-ray] once or at regular intervals is not recommended". A corrected claim was received with billed diagnosis F17.210 (Nicotine dependence, cigarettes, uncomplicated); however, this is also not an appropriate diagnosis for procedure code 71046 based on the American College of Chest Physicians and the American College of Radiology.  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 X-ray of the chest have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray of the chest (71046) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nerve conduction study billed for services provided on February 11, 2021.  You asked the Plan to pay for the services provided. You say that the records support necessity of services. The Plan denied your request. The Plan says the billed code cannot be verified.  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 95912 is nerve conduction studies; 11-12 studies. We find that CPT code 95912 is not supported in the medical record. Each study is reported once per nerve even when multiple sites of the same nerve are studied. 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 nerve conduction study billed for services provided on February 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Azathioprine 50mg tablet for the enrollee.  

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is covered by the pharmacy benefit.  

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   

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 drug. Our reviewer says that  Our physician reviewer found this is medically 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Azathioprine 50mg tablet for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says per the Plan EOC, members are allowed 10 one-way trips every year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid (87798) provided on June 24, 2021.  You asked the Plan to pay for code 87798. 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, the CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.  We find that CPT code 87798 is not supported in the medical record. Specifically, this service was billed with modifier 91. This modifier may not be used when tests are rerun to confirm initial results, or due to testing problems with specimens or equipment. Modifier 91 may only be used for laboratory test(s) performed more than once on the same date on the same enrollee. Review of the documentation does not support the correct billing of modifier 91 for these services. Based on this information, we decided that Medicare rules for coverage of code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid (87798) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine provided on April 26, 2021.  You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a shingles vaccine is not covered under your Medicare Part B benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on April 26, 2021.   Benefits for the shingles vaccine 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 January 25, 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.  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 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 laboratory services provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 provided on July 14, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 14, 2021.  

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code cannot be verified.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. The claim identifies the place of service as an independent laboratory. The records provided do not show that the specimen at issue was obtained at an independent laboratory. 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 lab services provided on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that the enrollee has been denied the right to be safe in the bath/shower. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cystourethroscopy (52352) provided on July 1, 2021.   You asked the Plan to pay for the cystourethroscopy (52352). You say that the medical records are attached for proper processing of code 52352. The Plan denied your request. The Plan says 52352 is included with 52356 and cannot be separately reimbursed.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 cystourethroscopy (52352) Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Modifier 59 is not supported by the documentation, as procedure was performed on the same side. Our physician reviewer found that CPT 52352 should not be reported separately from CPT 52356.  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 cystourethroscopy (52352) have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy (52352) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a continuation of care with an out of network (OON) provider.
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that you have had several issues with your arm and have found relief with the requested provider for over 10 years. You say that you have now lost feeling in 3 of your fingers on your right hand and it's locked up. You say that you would like the doctor you have been seeing to continue treating you. The Plan denied your request. The Plan says that there are network providers who can treat the enrollee's condition.
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. The rules also say that plans must ensure continuity of care for enrollees. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not send any medical records or evidence of having made reasonable attempts to obtain these medical records. Without medical documentation, we are unable to evaluate whether it is medically necessary for the enrollee to continue seeing the provider she has been seeing. We cannot properly evaluate whether the Plan can ensure continuity of care. The documentation was not provided to substantiate the Plan's denial reason. Therefore, we decided that the Plan has to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Genesight testing (81479) provided on August 18, 2021.  

You asked the Plan to pay for Genesight testing. You say that this was medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that in order for Pharmacogenomics Testing services to be covered, the patient's medical record must clearly reflect that the criteria listed in the rules section have been met.  

We looked at the file and Medicare rules. The submitted medical records do not include records from the ordering provider demonstrating that the criteria for coverage have been met and that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on August 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Renflexis (Q5104).  You asked the Plan to pre-approve Renflexis. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Inflectra or Remicade.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Renflexis. Our reviewer says that Renflexis is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the preferred drugs, Inflectra or Remicade. The reviewer also found that he record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred drugs. Therefore, the reviewer found that the request for Renflexis is not medically necessary as the step therapy criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Renflexis have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Renflexis (Q5104).