Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from February 12, 2021, to April 21, 2021.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you would like the copayments paid because the provider did not inform you of your financial responsibility. The Plan denied your request. The Plan says you have been asked to pay 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 each Medicare-covered physical therapy and/or speech and language pathology visit.
You have been asked to pay a $35 copayment for each of the physical therapy visits. ($35 x 13 visits = $455). The physical therapy visits fall within the "Outpatient Rehabilitation 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 copayments for the physical therapy visits provided from February 12, 2021, to April 21, 2021.
Your complaint about the poor manner in which the provider conducts business 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), pulp vitality tests (D0460), treatment of root canal obstruction (D3331), and additional intraoral periapical x-ray (D0230) provided on April 28, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, treatment of root canal obstruction, and additional intraoral periapical x-ray. You say that two of your teeth are calcified and need special and extensive treatment. The Plan denied your request. The Plan says the cone beam CT capture and interpretation, pulp vitality tests, and treatment of root canal obstruction are not covered services. The Plan also says that your benefits intraoral x-rays have been satisfied and the frequency limitation has been exceeded.
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 cone beam CT capture and
interpretation (D0364), pulp vitality tests (D0460), and treatment of root canal obstruction (D3331) are not
among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure
code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on April
28, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the cone beam CT capture and interpretation (D0364), pulp vitality tests (D0460), treatment of
root canal obstruction (D3331), and additional intraoral periapical x-ray (D0230) provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 21, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362, and L36523 to support their denial. However, LCD L36139, L36129, L36362, and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129, L36362, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high activity knee control frame (L5930) and a protective outer surface covering system (L5964).
You asked the Plan to pre-approve a high activity knee control frame and a protective outer surface covering system. You say that these items are medically necessary. The Plan denied your request. The Plan says that you are stated to be a K3 ambulator and that the records provided do not indicate you are exposed to harsh conditions or engages in extraordinary activities that require extra protection from a specialized prosthetic cover.
The Plan must follow Medicare rules. Medicare rules say that a high activity knee control frame is covered for beneficiaries whose functional level is 4 and that protective outer surface covering systems are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis. 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 high activity knee control frame and a protective outer surface covering systems. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You are a K3 level ambulator and the documentation does not support that you are exposed to unusually harsh environments. Our physician reviewer found that your condition does not meet Medicare criteria for these items. 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 high activity knee control frame and a protective outer surface covering systems have not been met. Therefore, we decided that the Plan does not have to pre-approve a high activity knee control frame (L5930) and a protective outer surface covering system (L5964).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on April 26, 2021.
You asked the Plan to waive the copayment for these services. You say that you are not happy with the copayment amount. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Medicare-covered observation care.
Review of the file shows that you received outpatient hospital services on April 26, 2021. Per the contract with the Plan, there is a $200 copayment for Medicare-covered observation care. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $143.97. Given that the allowed amount was less than the $200 copayment, you have been asked to pay $143.97 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $30 copayments charged for physician services provided
from April 7, 2021, to April 14, 2021.

You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct.
The Plan denied your request. The Plan says these copayments were charged based on the Plan contract
agreement.

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 $30
copayment for physician visits.

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 $30 copayments charged for physician services provided from April 7, 2021, to
April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (77002) provided on June 2, 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 77002 has a bundled relationship with code 73201 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 (77002) provided on June 2, 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.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for mental status changes, a fall, and a urinary tract infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has inflammatory arthritis
and rheumatoid arthritis. She has not tried and failed the Plan's required drugs of Humira, Enbrel, Xeljanz, or
Rinvoq. The records do not support that the required drugs would be contraindicated or less effective;
therefore, Simponi Aria is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Simponi Aria.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on April 22, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head).
Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 2, 2021.
You asked the Plan to pay for the services provided. You say that physician's send specimens for testing. The
Plan denied your request. The Plan says the specimen was obtained in an office setting.
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 the claim listed the place of service as an independent laboratory. The records do not indicate the
specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay
for the drug testing services provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for in injection of triamcinolone acetonide (a Part B drug), magnetic resonance imaging (MRI), X-Ray examination, and specialist office visits provided from January 2, 2021, to February 24, 2021.
You asked the Plan to waive the cost-sharing for Part B drug, MRI, X-Ray, and specialist visits. You say that you are appealing these charges. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.
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 Part B drug, $300 copayment for MRI, $20 copayment for X-Ray, and $50 copayment for each specialist visit. For the MRI on January 2, 2021 you have been asked to pay $300 copayment. The allowed amount of the Part B drug on February 2, 2021 is $11.04, resulting in a coinsurance amount of $2.21. For the X-Ray on February 2, 2021 you have been asked to pay $20 copayment. For the office visit on February 2, 2021 you have only been asked to pay $30 copayment, which is less than the $50 copayment for a specialist visit. For the office visit on February 24, 2021 you have been asked to pay $50 copayment. Your total cost-sharing amount is therefore $402.21. You have been asked to pay 20% coinsurance for Part B drug, $300 copayment for MRI, $20 copayment for X-Ray, and $50 copayment or less for each specialist visit. Part B drug, MRI, X-Ray, and specialist visits fall within the "Medicare Part B Prescription Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 cost-sharing for in injection of triamcinolone acetonide (a Part B drug), magnetic resonance imaging (MRI), X-Ray examination, and specialist office visits provided from January 2, 2021, to February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 18, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36358 to support their denial. However, LCD L36358 is not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36358 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne test provided on March 26, 2020 by an
out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that the test was medically necessary to assist in
treatment decisions. The Plan denied your request. The Plan says utilization of network providers and
authorization for certain services are 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 Plan did not pre-approve the testing
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 FoundationOne test provided on March 26, 2020 by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V Leiden, CALR, and MPL genetic testing.

You asked the Plan to pre-approve Factor V Leiden, CALR, and MPL genetic testing. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for these tests is correct, because Factor V Leiden testing is only covered for pregnant women and CALR and MPL testing require prior JAK2 test results to determine medical necessity.

The Plan must follow Medicare rules. Medicare rules say that Factor V Leiden is non-covered outside of pregnant women, and CALR or MPL may be covered under certain circumstances including that JAK2 V617F mutation analysis was previously completed and negative.

We looked at the file and Medicare rules. Factor V Leiden testing is not covered for this enrollee because the record does not show that the enrollee is pregnant. Additionally, CALR and MPL testing is not covered at this time because the JAK2 V617F mutation analysis has not been completed. The Plan approved coverage for JAK2 testing, you may consider contacting the Plan regarding CALR and MPL testing after the JAK2 testing is completed. Based on this information, we decided that Medicare rules for coverage of Factor V Leiden, CALR, and MPL genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor V Leiden, CALR, and MPL genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on June 5, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (duplex scan of arterial flow). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on June 5, 2021.