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

 We decided that the Plan does not have to pay for the Corus testing provided on September 22, 2020.  You asked the Plan to pay for the testing services. You say that the diagnosis code is covered. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing for suspected or documented cardiovascular disease.  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.  We looked at the file and the rules. The medical records provided do not show that the testing was ordered for a specific medical problem. The test at issue in this appeal, the testing services, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the Corus testing provided on September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on February 17, 2020.  You asked the Plan to waive the copayment for the ambulance services. You did not provide an argument in your appeal request. 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 $150 copayment per trip for ambulance services.   You have been asked to pay a $150 copayment per trip for the ambulance services. 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 ambulance services you received on February 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for tenodesis of a long tendon (23430) provided on January 12, 2021.  You asked the Plan to pay for the tenodesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support 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 23430 is tenodesis of long tendon of biceps.  We asked our coder 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 tenodesis. Our reviewer says that CPT code 23430 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not support CPT 23430 as a distinct separate procedure.  Modifier 59 is used to identify procedures/services, other than evaluation and management services, that are not normally reported together, but are appropriate under the circumstance. Modifier 59 should be used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tenodesis have not been met. Therefore, we decided that the Plan does not have to pay for tenodesis of a long tendon (23430) provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenomics testing provided on September 3, 2020.  You asked the Plan to pay for the testing services. You say that the test informs clinicians which medications may require dose adjustments. The Plan denied your request. The Plan says the testing has not been shown to be useful.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications.    The file shows that GeneSight pharmacogenomics testing was provided. We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the enrollee's treating physician is specifically considering using a drug, because a clear evidence-base or individualized factors make it one of the most appropriate potential treatments, and that medication has a clinically important drug-gene interaction. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing provided on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial nursing facility care provided on February 19, 2020.  You asked the Plan to pay for the initial nursing facility care. You say that you would like these charges to be reconsidered because the enrollee was inpatient. The Plan denied your request. The Plan says this claim was received on June 26, 2021, which is past the allowed 12-month timeframe.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the initial nursing facility care was not filed until June 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on September 10, 2020.  You asked the Plan to pay for the GeneSight Psychotropic test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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.  We find that CPT code 81479 is not supported in the medical record. Specifically, this code was not billed with the appropriate DEX-Z code. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic test have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on September 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 19, 2021, by an OON provider.  You asked the Plan to pay for the skilled nursing facility (SNF) care. You say that the enrollee was in a nursing home setting at the time the services were rendered. You say that there are no in network doctors who can treat the enrollee in this facility. You also say that most care is urgent. The Plan denied your request. The Plan says there is no authorization on file for the services rendered.  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 facility is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 19, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) and osteopathic manipulative treatment (OMT) (98929) provided on June 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care and OMT. You say that previous claims were covered under a submitted authorization. The Plan denied your request. The Plan says the skilled nursing facility level of coverage had ended prior to this date of service and there is no authorization is on file for these 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) and osteopathic manipulative treatment (OMT) (98929) provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the adjacent tissue transfer or rearrangement services coded 14301 provided on June 4, 2021.  You asked the Plan to pay for the adjacent tissue transfer or rearrangement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the 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. In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.  We find that CPT code 14301 is supported in the medical record. Specifically, the Plan states that this code is supported in the operative note; however, is considered inclusive to code 19303 (Mastectomy, simple, complete) and therefore, is not separately payable. However, we have confirmed that code 19303 is not a column II code to column I code 14301. This means that these codes are separately payable. The Plan has not substantiated their denial. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement services have been met. Therefore, we decided that the Plan has to pay for the adjacent tissue transfer or rearrangement services coded 14301 provided on June 4, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the biopsy procedure you had at a dermatologist's office on July 22, 2021.  You asked the Plan to waive the copayment for the biopsy procedure. You say that you were told that a single copayment covered all of your appointments. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan contacted the dermatologist's office and they advised that they did not tell you that there would only be one copayment for these two procedures.  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 per visit for specialist services.   Records show that you had a biopsy procedure on July 9, 2021.  You then had a second biopsy procedure on July 22, 2021, to remove additional tissue.  You have been charged a $50 copayment for the biopsy procedure you had at the dermatologist's office on July 22, 2021. This is a separate and distinct service from the services you received on July 9, 2021.  That means that separate cost sharing can apply. You have been asked to pay a $50 copayment per visit for the biopsy procedure. The biopsy procedure falls within the specialist 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 biopsy procedure you had at a dermatologist's office on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Minuteman F3-R plate system device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the requested device is considered experimental and investigational.  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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this system is experimental in spinal surgery. More research is needed to show safety and efficacy of the device.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Minuteman F3-R plate system device for the enrollee.
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 on June 23, 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 must 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 on June 23, 2021.
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 on June 24, 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 on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a hardware injection block.  You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says these blocks are considered experimental, investigational, and unproven.  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 the block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this would be considered an experimental and investigational procedure. Therefore, this request is deemed not medically reasonable or 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a hardware injection block.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the paramedic intercept (A0432), provided on May 25, 2021.  You asked the Plan to pay for the paramedic intercept. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.   The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept (A0432), provided on May 25, 2021.
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 on April 1, 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 must 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 on April 1, 2021.
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 on July 21, 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 must 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 on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for determination of refractive state (92015) provided May 13, 2021.  You asked the Plan to pay for the refraction services. You say that it clearly states in your member materials that a final refraction is covered after cataract surgery. The Plan denied your request. The Plan says the provider needs to submit a correct claim with the diagnosis pointer corrected.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered after cataract surgery.  We looked at the file and the Plan's rules. The refraction service is only covered by Medicare after cataract surgery. This means that the refraction would have to be paired with the cataract surgery diagnosis code. In this case, the provider incorrectly billed this with diagnosis pointer 3 for Presbyopia. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015) provided May 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic testing services provided on March 14, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an additional modifier is needed to be 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 codes 70450, 71045, 72125 were billed twice on the same day. The services were provided by different physician. The claim information does not show that the services were billed with a modifier to indicate another physician repeated the procedure in a separate session. 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 diagnostic testing services provided on March 14, 2021.