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

We decided that the Plan does not have to pay for the radiology services provided on April 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the provider should have requested authorization for these services. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 referring provider is also 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 radiology services provided on April 24, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cancer panel (81479, 81435, 81408, 81308, 81162, 81406, 81405, 81404, 81403) provided on February 19, 2021.
You asked the Plan to pay for a comprehensive cancer panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. We looked at the file and Medicare rules. The records do not show that the testing at issue was ordered by a physician. Of note, the order form in the file was not signed. Based on this information, we decided that Medicare rules for coverage of a comprehensive cancer panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cancer panel (81479, 81435, 81408, 81308, 81162, 81406, 81405, 81404, 81403) provided on February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient behavioral health therapy (90853) provided from January 26, 2021, to February 26, 2021.
You asked the Plan to waive the copayments for the outpatient therapy services. You say that you did not have therapy on every date at issue, and you only had group therapy even though your bill shows individual therapy services. The Plan denied your request. The Plan says they were unable to obtain medical records from the provider to verify whether or not you received the services on every date in question. However, the copayments for these services were applied in accordance with your contract.
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 $50 copayment for mental health services provided in an outpatient hospital setting.
You have been asked to pay a $50 copayment for each day of outpatient mental health therapy services. These services were provided in an outpatient hospital setting. 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 copayments for the outpatient behavioral health therapy (90853) provided from January 26, 2021, to February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided January 13, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you never received an ultrasound with a doppler. Your primary care physician would send you out to see a specialist for that. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $25 copayment for carotid or peripheral vascular ultrasound. You have been asked to pay $25 copayment for the diagnostic service. The diagnostic service 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 the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided January 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs may be met in home health services and supervision at home, in an assisted living facility, or part-time skilled services in long-term care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463)
provided May 25, 2021.
You asked the Plan to waive the copayment for the outpatient visit. You say that you were not aware they will
charge a facility charge. You saw 3 other doctors in that same building before and never got billed for this. If
you knew they were going to charge a facility charge you would not have gone. The Plan denied your request.
The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $325
copayment for each Medicare covered non-surgical visit in an outpatient clinic.
You have been asked to pay $128.35 $325 copayment for the outpatient visit. Since the allowed amount was
less than the Plan's copay amount, you are responsible for the lesser amount. The outpatient visit falls within
the Outpatient hospital 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 hospital outpatient clinic visit (G0463) provided May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on March 16, 2021, to
April 1, 2021, by an OON provider.
You asked the Plan to pay for the acupuncture services. You say that due to a car accident in August 2019, you
are seeking treatment for chronic pain and feel that acupuncture has been helpful and believe this service
should be paid for. The Plan denied your request. The Plan says enrollees must receive acupuncture services
from an in-network provider.
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 acupuncture services provided on March 16,
2021, to April 1, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee in June 2, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee in June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a tube placement and anchor (30999, 44500) provided March 26, 2021.
You asked the Plan to pay for the tube placement and anchor. You say that the service was medically necessary. The Plan denied your request. The Plan says these services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 30999 and 44500 is not supported in the medical record. Specifically, payment for this service is bunded with the inpatient DRG payment. Based on this information, we decided that Medicare rules for coverage of the tube placement and anchor have not been met. Therefore, we decided that the Plan does not have to pay for a tube placement and anchor (30999, 44500) provided March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is a more appropriate code for these services.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 must be billed with code 81479 for coverage consideration. We looked at the file and Medicare rules. In this case, the requested Guardant360 testing was billed with multiple codes. Per the applicable LCA, Guardant360 testing must be billed with code 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on May 10, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 76705 was billed with code 93976. The rules say that the billed services may be justifiable when an appropriate modifier is used. The claim does not show that the service at issue was billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on May 10, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve PET scan. You say that this is medically necessary. The Plan denied your request. The Plan says that this test is not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 PET scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested PET scan. Our physician reviewer found this request is for a dotatate PET scan which is specialized for carcinoid tumors. The enrollee cannot do a computed tomography (CT) scan due to renal dysfunction and cannot do magnetic resonance imaging (MRI) due to metal. This PET is done once per year for surveillance. This is medically reasonable and 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
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 a prolonged office visit (99417) provided on April 2, 2021.
You asked the Plan to pay for a prolonged office visit. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a valid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99417 is not supported in the medical record.
Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of a prolonged office visit have not been met. Therefore, we decided that the Plan does not have to pay for a prolonged office visit (99417) provided on April 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on April 28, 2021.
You asked the Plan to waive the copayment for the breast ultrasound (76642). You say that you were following medical advice and should only have an office visit copayment. 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 $125 copayment for other outpatient diagnostic tests. You have been asked to pay a $81.76 copayment for the breast ultrasound (76642). The breast ultrasound (76642) falls within the other outpatient diagnostic tests. benefit category. The copayment is less than required because the Medicare allowable for this procedure is less. 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 breast ultrasound provided on April 28, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that there is not one at home to help the enrollee to recover. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for mechanical falls. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on April 19, 2021.
You asked the Plan to pay for these services. You say that you had the vaccine to ensure your wellness and prevent disease. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on April 19, 2021.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for OTC Preservision eye vitamin purchased on April 30, 2021.
You asked the Plan to pay for the item. You say that you have been taking Preservision for three (3) years and feel it should be reimbursed. The Plan denied your request. The Plan says they are unable to take any action on this claim without a doctor's recommendation for the vitamin.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the item have not been met. They Plan has not received the required documentation or information to process this claim after sending multiple requests and, therefore, your claim has been denied due to a lack of information. Therefore, we decided that the Plan does not have to pay for OTC Preservision eye vitamin purchased on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (4342) provided on February 10, 2021.
You asked the Plan to pay for scaling and root planing. You say that your dental provider was booked for a long time, and you just took the appointment that was available, and you did not know when you would be able to get another. The provider recommended these services. The Plan denied your request. The Plan says periodontal scaling and root planing services can only be covered once every 36 months. You previously had scaling and root planing provided in March of 2018, which is less than 36 months before the date in question.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover non-surgical periodontal procedures, such as scaling and root planing, once per quadrant every 36 months. Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling and root planing is requested in a frequency that is not covered under this benefit. Documentation shows you previously had this service provided for this quadrant in March of 2018, which is less than 36 months before the date in question.
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (4342) provided on February 10, 2021.
Your complaint about a potential exception to the rule due to scheduling and the services being provided at almost 36 months is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64450) provided on March 23, 2021.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says this is a bundled service.
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 64450 has a bundled relationship with code 01402 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 services (64450) provided on March 23, 2021.