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

 We decided that the Plan does not have to pre-approve a PET scan of the brain (78608).  You asked the Plan to pre-approve a PET scan of the brain. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because there is no documentation to support a diagnosis of Frontotemporal dementia.  The Plan must follow Medicare rules. Medicare rules say that an FDG PET scan is reasonable and necessary in patients who meet diagnostic criteria for both AD and FTD.   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 PET scan of the brain. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the records in this case do not readily support a clinical presentation suggestive of you having both Alzheimer's disease and Frontotemporal dementia as required by the Medicare rules. There were not any symptoms to suggest the presence of Frontotemporal dementia at present.  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 PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve three office visits and treatment to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve three office visits and treatment to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan provided on August 10, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that the approval you received from the Plan for the scan did not indicate that you would be responsible for a copay. You say you do not feel you should have to pay it. The Plan denied your request. The Plan says you have been 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 $100 copayment for each complex diagnostic radiology service, including CT scans.   You have been asked to pay a $100 copayment for the CT scan. The CT scan 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 computed tomography (CT) scan provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on June 15, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.   We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve spinal surgery services.  You asked the Plan to pre-approve spinal surgery services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.  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 pre-approve spinal surgery services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of a trial and failure of physical therapy for back pain. More conservative measures are needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery services have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve facet joint injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain indications.     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 facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have low back pain due to lumbar spinal stenosis and idiopathic scoliosis with associated neuroclaudicaiton and radiculopathy. You have tried and failed medical therapy, physical therapy, epidural steroid injection and a steroid injection. You have low back pain with both axial and radicular manifestations. The documentation shows that you do not have a diagnosis/condition that meets criteria for the requested services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (46200) provided on April 23, 2021.  You asked the Plan to pay for the services. 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 46200 is a column II code to column I code 46255. This claim has not been billed with an appropriate modifier to bypass the edit. 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 (46200) provided on April 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 17, 2021.  You asked the Plan to pay for the ambulance service. You say that your daughter called for an ambulance. You say that the paramedics recommended that you go to the emergency room. You say that you declined because you did not feel the way you felt the last time you had a transient ischemic attack (TIA). You also say that you would like this bill to be covered. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since no transport took place, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on April 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 5 additional physical therapy visits.  You asked the Plan to pre-approve 5 additional physical therapy visits. You say that you enclosed documentation in support of this claim. The Plan denied your request. The Plan says additional visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.    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 5 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the patient has had prior therapy for this condition and has been instructed in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and unspecified oral surgery service (D7999) provided from July 15, 2021, to July 16, 2021.  You asked the Plan to pay for the dental services. You say that in a statement sent to you by your dentist, code D7999 was for surgical and anesthetic supplies. You say that you have a very limited income. You also say that you feel you should not be responsible for this bill. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that the unspecified oral surgery service is not listed as 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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for this service that you received on July 5, 2021. Additionally, the unspecified oral surgery service, noted to be surgical supplies, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and unspecified oral surgery service (D7999) provided from July 15, 2021, to July 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the bone and joint imaging service and the computed tomography (CT) scan you had on August 11, 2021.

You asked the Plan to waive the copayments for the bone imaging and the CT scan. You say that you do not know why these tests were ordered because nothing was wrong with you. You said that you are being charged all of these copayments separately. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the CT scan, because the allowed amount for that service ($169.35) is less than your copayment obligation, you are only responsible for the allowed 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 basic imaging services and a $200 copayment for advanced imaging services.

You have been asked to pay a $35 copayment for the bone imaging and a $200 copayment for the CT scan. The bone imaging and falls within the basic imaging services benefit category and the CT scan falls in the advanced imaging services benefit category. These copayments apply regardless of the reason for these tests and regardless of what other related services you may receive at the same time. 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 bone and joint imaging service and the computed tomography (CT) scan you had on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on June 3, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that only CPT code 81479 is covered for Guardant360 testing. We looked at the file and Medicare rules. In this case, the Guardant360 testing was billed with multiple codes. Per, LCA A58192, Guardant360 testing is to be billed with CPT code 81479 for coverage to be considered. 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 June 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on May 17, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says your Plan covers ambulance transportation only when you are actually transported by
ambulance. Since you were not transported by this ambulance, the service is not covered by your Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on May 17, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on May 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy sessions provided by a participating provider.

You asked the Plan to pre-approve speech therapy. You say that these additional sessions are medically necessary. The Plan denied your request. The Plan says these additional sessions are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 speech therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional speech therapy sessions provided by a participating provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for laboratory services provided on June 17, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you do not remember going to the hospital on June 17, 2021. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

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 did not provide medical records in the case file. Without medical records we cannot determine whether or not laboratory services were received on June 17, 2021. Therefore, we decided that the Plan has to waive the copayment for laboratory services provided on June 17, 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 the limited oral evaluation (D0140), endodontic therapy (D3310), and apicpoectomy (D3410), provided on February 25, 2021 and April 14, 2021.  You asked the Plan to pay for the limited oral evaluation, endodontic therapy, and apicpoectomy. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.  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. Specifically, the services you obtained are not listed in the Plan's benefit chart. This means they are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), endodontic therapy (D3310), and apicpoectomy (D3410), provided on February 25, 2021 and April 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the dialysis services provided from November 2, 2020, through November 23, 2020.  You asked the Plan to waive the coinsurance for the dialysis services. You say that you received a bill, but you thought the charges had been taken care of. You say you received an Explanation of Benefits that showed $0 responsibility and another one that showed copays. The Plan denied your request. The Plan says you have been 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 20% coinsurance for each visit for outpatient dialysis treatments and services.   You have been asked to pay 20% of the allowed amount for the dialysis services.  Date of Service Allowed Amount 20% Coinsurance November 2, 2020 $270.62 $54.12 November 4, 2020 $270.62 $54.12 November 6, 2020 $270.62 $54.12 November 9, 2020 $270.62 $54.12 November 11, 2020 $270.62 $54.12 November 13, 2020 $270.62 $54.12 November 16, 2020 $270.62 $54.12 November 18, 2020 $270.62 $54.12 November 20, 2020 $270.62 $54.12 November 23, 2020 $270.62 $28.20 (yearly maximum out of pocket has been met) TOTAL:  $515.28  The dialysis services fall within the Services to Treat Kidney Disease benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the dialysis services provided from November 2, 2020, through November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin-based composite (D2393) for tooth #32.
You asked the Plan to pre-approve the resin-based composite. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, restorative services are limited to 1 amalgam, resin, or composite filling per tooth, every 3 years. The record shows that the enrollee received a resin-based composite (D2393) on tooth #32 on May 6, 2021 and the enrollee's resin-based composite benefit for tooth #32 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a resin-based composite (D2393) for tooth #32.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (99153) provide don July 14, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable.  The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting.   We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provide don July 14, 2021.