Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of hot or cold packs (97010) provided on July 14, 2021.
You asked the Plan to pay for the application of hot or cold packs. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim is specifically not eligible for payment.
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 97010 is application of a modality to 1 or more areas; hot or cold packs.
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 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 97010. Based on this information, we decided that Medicare rules for coverage of the application of hot or cold packs have not been met. Therefore, we decided that the Plan does not have to pay for the application of hot or cold packs (97010) provided on July 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (CPT code 64634).
You asked the Plan to pre-approve the services. You say that the services are medically necessary to regain function in your neck without pain. The Plan denied your request. The Plan says your request is not medically necessary because your records show you did not have at least 80% pain relief with your two (2) MBBs.
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 services. Our physician reviewer found a radiofrequency ablation is indicated after the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). In this case, you did not have at least 80% pain relief with prior two (2) MBBs. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT code 64633) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (CPT code 64634).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing provided on February 26, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the billing record indicates that the enrollee has ischemic heart disease and Gaucher's disease, whereas the order form indicates schizophrenia and bipolar disease. No primary source medical records were submitted. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetic testing provided on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the genetic testing. 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for genetic testing provided on July 26, 2021, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychological testing evaluation service (96130) rendered by the out-of-network (OON) provider on June 1, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the psychological testing evaluation service (96130) rendered by the out-of-network (OON) provider on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675)
provided on May 5, 2021.
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue were a
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices
are not covered by Medicare for prevention of deep venous thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression
devices (E0673, E0675) provided on May 5, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on June 8, 2020.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this 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 dental
services received on June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, head or brain (70450) provided July 7, 2021.
You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Attached are the reports to support the level of service. Please reconsider for processing. The Plan denied your request. The Plan says this is an unbundled service. A national correct coding initiatives (NCCI) procedures to procedure (PTP) edit exists between 70496 and 70450.
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 70450 is a column II code to column I code 70496. 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 computed tomography, head or brain (70450) provided July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a custom fabricated oral appliance to reduce upper airway
collapsibility (E0486) provided on June 15, 2021.
You asked the Plan to pay for an oral appliance. You say that this is supported in the records. The Plan denied
your request. The Plan says the records do not include a physician order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. Specifically, the
submitted records contain only a prescription for an "oral appliance" that does not specify the item provided.
The record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for a custom fabricated oral appliance to reduce upper
airway collapsibility (E0486) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit you had on May 3, 2021.
You asked the Plan to waive the copayment for the podiatry visit. You say that the doctor's secretary did not tell you that the foot measurement services with the podiatrist would be considered an office visit. You said that you were in the podiatrist's office for three minutes, so you think this charge is excessive. 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 $50 copayment for services with a podiatrist. You have been asked to pay a $50 copayment for the podiatry visit. This copayment applies each time you see the podiatrist, regardless of how long the visit lasts. 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 podiatry visit you had on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the enrollee on March 12, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not appropriate for the service billed.
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, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 anesthesia services (procedure code 99100) provided to the enrollee on March 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for urgent care services you received on July 14, 2021.
You asked the Plan to waive the copayment for the urgent care services. You say that your Annual Notice of Change says that you pay $0 for urgent care services. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for [Enter category in plan contract from which cost sharing was applied]. The burden is on the Plan to prove that their assessment of cost sharing is correct. In this case, you provided a copy of your 2021 Annual Notice of Change that states that urgent care services have a $0 copayment. The Evidence of Coverage says that you pay a $35 copayment for urgent care services. The Plan has failed to address this discrepancy in any way in the case file it sent to us. In cases where the Plan fails to substantiate its argument, we must analyze the facts of the case and the contract documents in the light most beneficial to the enrollee. Because there is a discrepancy between the Annual Notice of Change and the Evidence of Coverage, as the drafter of these two documents, the Plan is responsible for ensuring that they are clear. They have failed to do so. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for urgent care services you received on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provider (PCP) on June 14, 2021.
You asked the Plan to waive the copayment for the PCP visit. You say that your doctor drew blood in connection with your preventive physical which you completed after this visit, so you don't think you should have to pay a 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 $10 copayment for visits with your PCP. We looked at the medical records from this date of service. The medical records do not show this was an annual wellness visit or annual physical. Rather, the records show that you saw this doctor to evaluate how you were doing after your Coronavirus infection. Your symptoms had reportedly improved 85% and your vertigo was gone. There is nothing in the records to show this was one of the preventive visits listed above. You have been asked to pay a $10 copayment for the PCP visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provider (PCP) on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 27, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not contain sufficient medical records to determine that the elements of the coverage criteria are satisfied. The requested test appears to be requested for screening purposes. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you want to go to the SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the office visit charges, electrical stimulation, unlisted physical medicine services, and shoe inserts provided by an out-of-network (OON) chiropractor from January 4, 2021, through March 31, 2021.
You asked the Plan to provide additional reimbursement for the chiropractor services other than spinal manipulation. You say that you were having back pain, and this provider came highly recommended. You had 24 sessions which completely treated your pain. You understand that since this provider is OON that you would not be reimbursed the full amount paid, but you believe that the amount reimbursed is not enough. The Plan denied your request. The Plan says you have been reimbursed 50% of the Medicare-allowed amount for the spinal manipulation services. All other services provided by this chiropractic are not covered by Medicare.
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. The documentation shows that the Plan paid its portion of the Medicare-allowed amount for the OON chiropractic services.
Therefore, we decided that the Plan does not have to provide additional reimbursement for the office visit charges, electrical stimulation, unlisted physical medicine services, and shoe inserts provided by an out-of-network (OON) chiropractor from January 4, 2021, through March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral, periapical first x-ray (D0220) and intraoral, periapical each additional x-ray (D0230) provided July 8, 2021.

You asked the Plan to pay for the dental x-rays. You say that you would like to appeal because the dentist completed services that were not covered. Nothing was explained to you they just did the services. The Plan denied your request. The Plan says this service exceeds the benefit's frequency limitation.

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 health Plan contract says that 1 dental x-ray is covered per year. The records show that the Plan had approved and paid for procedure code D0330 (panoramic x-rays) that was also provided on this same date of service. 

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 at this time as the benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the intraoral, periapical first x-ray (D0220) and intraoral, periapical each additional x-ray (D0230) provided July 8, 2021.