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

We decided that the Plan has to pay for pharmacogenomic testing provided on April 12, 2021.

You asked the Plan to pay for pharmacogenomic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.

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 was 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 constituted plan-directed care. 

The Plan says that this testing was coded incorrectly because a multi-gene panel must be billed with a single procedure code; however, this coding rule does not have Medicare Part B jurisdiction in the state of Florida. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for pharmacogenomic testing provided on April 12, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology visit you had on June 8,
2021.

You asked the Plan to waive the copayment for the ophthalmology visit. You say that this copayment should be
waived because it was a follow-up from eyelid surgery. The Plan denied your request. The Plan says you were
charged this copayment 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 $15
copayment for medical eye exams.

You have been asked to pay a $15 copayment for the ophthalmology visit. The medical records from this visit
do not show that this was a follow-up from surgery. The records show that you were evaluated on this date for
brow ptosis and you were not interested in pursuing brow surgery. Because of this, the ophthalmology visit
falls within the medical eye exams 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 ophthalmology visit you had on June 8,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on April 5, 2021.
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that it took three root canal treatments to resolve the problem and you are being charged the full amount. You say that you were just trying to save the tooth and the office did not tell you how much you would be charged. The Plan denied your request. The Plan says you have met your annual out-of-pocket maximum.
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 $1,000 toward covered dental services. The Plan paid $1,000 toward the dental services received on January 13, 2021, February 23, 2021 and April 15, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical implant placement provided on April 12, 2021.
You asked the Plan to pay for the surgical implant placement. You say that you were advised dental implants are covered with 40% coinsurance. The Plan denied your request. The Plan says the service is not a covered benefit.
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 surgical implant placement provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for critical care services (99291) provided on June 2, 2021.

You asked the Plan to pay for critical care services. You say that this is supported in the records. The Plan
denied your request. The Plan says that the units billed exceed the Medically Unlikely Edits (MUE) for this
code.

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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has stated that this service denied because the Medically Unlikely Edits
(MUE) for code 99291 is 1 and 3 units were billed. However, the claim form included in the file shows 1 unit
was billed. No additional claims for this date of service were included in the file to show that additional units
were billed. The submitted medical records show that the billed code was appropriate for the time spent on
critical care. The Plan has not provided sufficient information to support their denial. Therefore, we decided
that the Plan has to pay for critical care services (99291) provided on June 2, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination provided on June 7, 2021.
You asked the Plan to pay for radiologic examination, spine, lumbosacral (72100). You say that you thought radiologic exams were covered. The Plan denied your request. The Plan says x-rays provided by a chiropractor are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the radiologic examination provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541,
87581, 87640, and 87798 provided on July 15, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 7486, 87496, 87498, 87541, 87581, 87640, and 87798 are not supported in the medical
record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the
enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim
history indicates that the specimen was obtained in an office setting place of service 11.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486,
87496, 87498, 87541, 87581, 87640, and 87798 provided on July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services billed with JAKC1 x 20 days and provided on
January 6, 2020, through January 26, 2020.

You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support
the diagnosis of Ulcerative Colitis.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.

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 SNF services. Our reviewer says that the
documentation was reviewed and does not meet criteria for billing or reimbursement consideration. Our
physician reviewer found per documentation by the physician the member was hospitalized due to re-current Cdiff,
and was diagnosed with IBS (irritable bowel syndrome) with not specified as recurrent ICD 10 A04.72.

The documentation does not support Ulcerative Colitis. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services billed with JAKC1 x 20 days and provided on January 6, 2020, through January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for patient of extreme age (99100) provided on September 15, 2020.
You asked the Plan to pay for Anesthesia for patient of extreme age. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim is always bundled into payment for other services and no separate payment is made.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure.) We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status
indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of Anesthesia for patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for patient of extreme age (99100) provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an oral exam (D0120) and cleaning (D1110) and three sets of X-rays (D0274, D0220, D0230).
You asked the Plan to waive the copayments for an oral exam and cleaning and three sets of X-rays. You say that you have never had to pay a copayment for dental services before and you should not have to now. The Plan denied your request. The Plan says the correct copayments were applied.
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 $15 copayment for an oral exam and cleaning and for X-rays. You have been asked to pay a $15 copayment for an oral exam and cleaning; a $15 copayment for a set of 4 bitewing X-rays; an $11 copayment for a first periapical X-ray; and a $9 copayment for an additional periapical
X_ray. An oral exam and cleaning and X-rays fall within the "Dental services" benefit category. This means that you have been asked to pay less than or equal to 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 copayments for an oral exam (D0120) and cleaning (D1110) and three sets of X-rays (D0274, D0220, D0230).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on May 23, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are billed are not 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. In this case, we have confirmed that code 76705 
for the ultrasound has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be 
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76705 provided on May 23, 
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81405, 81406) rendered by the out-of-network (OON) provider on April 29, 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 (81405, 81406) rendered by the out-of-network (OON) provider on April 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on July 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the service was 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. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 7, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical removal of a benign lesion.
You asked the Plan to pre-approve a surgical removal of a benign lesion. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is cosmetic in nature and therefore not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 a surgical removal of a benign lesion. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our reviewer found that the enrollee has a benign cyst over the zygomatic arch. The record does not indicate that the lesion clinically restricts vision. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a surgical removal of a benign lesion have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical removal of a benign lesion.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-emergent ambulance transport (A0428) and ground mileage (A0425) provided on April 10, 2021.
You asked the Plan to pay for the transportation services. You say that the enrollee needed to be transported via stretcher. The Plan denied your request. The Plan says that the non-emergent transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the transportation services. Our reviewer says that the transportation services are medically necessary. Our physician reviewer found the medical records provided indicate that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on April 10, 2021, due to his recent fall and cervical fracture and dementia. The reviewer found that the enrollee was not safe to be transported sitting. The reviewer found there is documentation that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on April 10, 2021 due to his requirement for stretcher transport, recent cervical fracture and dementia. The reviewer also found that the ambulance transport on April 10, 2021, was medically reasonable and necessary for the enrollee due to the need for the stretcher transport and the presence of the cervical fracture and underlying dementia. 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 transportation services have been met. Specifically, the file shows that the enrollee was not safe to be transported sitting. Therefore, we decided that the Plan has to pay for the non-emergent ambulance transport (A0428) and ground mileage (A0425) provided on April 10, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral bone graft procedure (D4263) provided on March 17, 2021.
You asked the Plan to pay for an oral bone graft. You say that you were unaware that the procedure at issue was not something covered by your dental plan. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an oral bone graft procedure (D4263) provided on March 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.  
You asked the Plan to pre-approve the requested services. You say that cooled radiofrequency ablation is the 
preferred method for lesioning. The Plan denied your request. The Plan says the service is not covered.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. Non-thermal modalities for facet joint denervation are considered 
not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on June 17,
2021, through June 30, 2021.

You asked the Plan to pay for the SNF care. You say that the service was medically necessary. The Plan denied
your request. The Plan says the service was not medically necessary.

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 pay for the SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found daily skilled services were not required to
establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care
needs, as a practical matter, could be provided at a lower level of care

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF care have not been met. Specifically, medically necessary services
could have been provided at a lower level of care. This means continued SNF care was not medically necessary
or reasonable. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF)
care, provided on June 17, 2021, through June 30, 2021.