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

 We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism (CPT code 87798) provided to the enrollee on December 21, 2020.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the enrollee are not a benefit. The Plan states these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.  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, the service, 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 infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism (CPT code 87798) provided to the enrollee on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (CPT code(s): 73620LT, R0075UP, Q0092) provided to the enrollee on June 9, 2021.  You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 services (CPT code(s): 73620LT, R0075UP, Q0092) provided to the enrollee on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardio genomics gene panel provided on April 29, 2021.  You asked the Plan to pay for the testing services. You say that the medical records support the services. The Plan denied your request. The Plan says genetic cardiovascular testing is excluded from Medicare coverage.  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.  We looked at the file and the rules. The records do not show that the enrollee's treating physician ordered the tests, or that the results would be used in the management of a specific medical problem. It appears that the test at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardio genomics gene panel provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on July 12, 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 laboratory services rendered by the out-of-network (OON) provider on  July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scooter lift provided on December 21, 2020.  

You asked the Plan to pay for the scooter lift. You say that the item should be covered. The Plan denied your request. The Plan says this is not a covered item.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the scooter lift provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 13, 2021, to January 18, 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 the DRG was updated.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    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 services at issue in this case were not supported by the medical records. Our physician reviewer found the records show that the enrollee presented tachycardia, tachypnea, leukocytosis, and altered mental status, but normal blood pressure and he responded to fluids and antibiotics. On admission, the enrollee was alert and oriented, but confused to day/time and place and was not in respiratory distress, unclear if this was near his baseline or not. The records did not clearly show signs of organ dysfunction related to the systemic infection to support the sepsis diagnosis. Therefore, the DRG was not correct.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 13, 2021, to January 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray; single view (CPT code 71045) provided to the enrollee on August 5, 2021.  You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The enrollee had professional interpretation of a chest x-ray by this provider on August 5, 2021. The submitted documentation supports 1 (one) unit of 71045-26, which was previously approved/paid. There is no additional documentation supporting an additional study by this provider which was billed and remains denied. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray; single view (CPT code 71045) provided to the enrollee on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 24, 2020.  

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed were already processed.  

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 71045 is radiologic examination, chest; single view.  

We find that CPT code 71045 is not supported in the medical record. Specifically, this claim was already processed and paid by the Plan. There is no documentation that supports additional x-ray services were provided for the same date of service. This means this claim is a duplicate and cannot be paid. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on February 1, 2021, through February 19, 2021.  You asked the Plan to waive the copayment for the SNF care. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says the cost share 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 $184 copayment per day 21-100; the first 20 days are covered for skilled nursing facility (SNF) care.   You have been asked to pay a $184 copayment per day 21-100; the first 20 days are covered for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. The documents submitted indicate the enrollee was in a SNF for 38 days. The first 20 days of their stay were covered and they are responsible for a copayment for the remaining 18 days. 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 skilled nursing facility (SNF) care provided on February 1, 2021, through February 19, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided August 17, 2021.  You asked the Plan to pay for the pulp vitality tests. You say that the provider was listed as in-network on the Plan's website. The Plan denied your request. The Plan says the claims from this date of service have been processed as in-network, however the pulp vitality tests are not a covered service.  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 pulp vitality tests (D0460) provided August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound debridement (G0463, 11042) provided on September 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for wound debridement. You say that the patient has been on ongoing treatment for a diabetic ulcer of the right foot with this provider since May of 2021. You also say that the patient had been scheduled for this appointment prior to August 1, 2021. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility.  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 at issue in this case is not a network provider with the Plan. 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 wound debridement. Our reviewer says that the services does not meet criteria. Our physician reviewer found Based on the medical records provided there is no documentation that it was medically reasonable and necessary for the member to see the out-of-network provider for the services rendered on 09/21/2021 as opposed to seeing an equivalently licensed and credentialed in-network provider.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound debridement have not been met.   The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for wound debridement. Therefore, we decided that the Plan does not have to pay for wound debridement (G0463, 11042) provided on September 10, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90837) provided on June 22 to July 6, 2021, by an out-of-network provider.  You asked the Plan to pay for psychotherapy services. You say that the enrollee has affirmed numerous times the benefit of your psychotherapy services during this challenging time. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 psychotherapy services (90837) provided on June 22 to July 6, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) rendered on July 16, 2021.  You asked the Plan to waive the copayment for a specialist office visit. You say that you do not believe you should be charged the copayment since you are still under the doctor's care per his instructions to do so. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $35 copayment for specialist visits for Medicare-covered services.   You have been asked to pay a $35 copayment for a specialist office visit. 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 specialist office visit (99213) rendered on July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee is medically stable for discharge from the hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay an additional amount, up to the Plan's eyewear benefit amount of $100 for the eyeglasses provided on October 1, 2021. We decided that the Plan does not have to pay for vision supply, accessories.  You asked the Plan to pay an additional amount for eyeglasses. The Plan says that the Plan has paid the correct amount for the eyeglasses.   We decided that the Plan has to pay an additional amount for up to the Plan's eyewear benefit amount of $100 for the eyeglasses provided on October 1, 2021.   We looked at the file and the Plan's rules. The file shows that the Plan covers a routine vision benefit with a $100 allowance combined in and out of network toward the purchase and fitting of eyeglasses and a pair of lenses or contact lenses (1 per calendar year). Therefore, we decided that the Plan has to pay an additional amount up to the Plan's vision benefit amount of $100 for the eyeglasses provided on October 1, 2021.   We also decided that the Plan does not have to pay for vision supply, accessories provided on October 1, 2021.  We looked at the file and the Plan's rules. The file shows that the Plan's routine vision benefit does not provide coverage for vision supply, accessories. Therefore, we decided that the Plan does not have to pay for vision supply, accessories provided on October 1, 2021.  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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on August 12, 2021.  You asked the Plan to pay for neuromuscular junction 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 providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.  We find that CPT code 95937 is not supported in the medical record. Specifically, this code was used to report train of four testing. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on August 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy (45378), provided on September 21, 2021.  You asked the Plan to waive the copayment for a colonoscopy. You say that there should be no copayment. The Plan denied your request. The Plan says the cost share 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $200 copayment for a colonoscopy. This service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Your provider billed this as a diagnostic service, not a preventative service. 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 (45378), provided on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tempus gene panel provided on March 4, 2021.  

You asked the Plan to pay for the testing services. You say that the test will guide appropriate medical management of the enrollee. The Plan denied your request. The Plan says the codes should not be unbundled.  

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 looked at the file and the rules. The file shows that the gene panel at issue was billed with multiple CPT codes. If a single procedure is performed, only one CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel provided on March 4, 2021.