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

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not supported.
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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed". We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not show that 22 or more drug classes were provided on the date of service in question. 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 (G0483) provided on May 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from March 23, 2021, to June 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that the acupuncture services were provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist, nor auxiliary personnel under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from March 23, 2021, to June 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by an out-of-network (OON) provider on May 4, 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 a primary care physician referral or 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, pre-approved care, and via the POS benefit option with a PCP referral. You are not a network provider with the Plan. The Plan did not receive a primary care physician referral and did not issue prior authorization for this service. 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 psychotherapy (90837) rendered by an out-of-network (OON) provider on May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy, with biopsy (45380) rendered on June 14, 2021.
You asked the Plan to waive the copayment for a colonoscopy, with biopsy. You say that you have not had any care since November 2019, and you feel this colonoscopy was medically necessary. You also say that you should not be responsible for the copay and that your last colonoscopy was covered in full. The Plan denied your request. The Plan says you were 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 $350 copayment for same day outpatient surgery in an outpatient hospital facility (includes diagnostic "scopes" such as an endoscopy).
You have been asked to pay a $350 copayment for a colonoscopy, with biopsy. A colonoscopy, with biopsy falls within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy, with biopsy (45380) rendered on June 14, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on May 18, 2021.
You asked the Plan to pay for drug testing. You say that you are appealing with records to support the necessity
of this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct,
because the documentation submitted does not support that 22 or more drug classes were included in testing.
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 G0483 is drug tests, definitive; qualitative or quantitative, all sources, includes specimen validity testing,
22 or more drug classes, including metabolites if performed.
We find that CPT code G0483 is supported in the medical record. Specifically, the documentation shows that
22 or more drug classes were included in this testing. Based on this information, we decided that Medicare
rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug
testing (G0483) provided on May 18, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on April 29, 2021.
You asked the Plan to waive the copayment for the dermatology visit. You say that the doctor was not in the room for more than five minutes, so you should not have to pay the 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 $20 copayment for visits with a specialist. You have been asked to pay a $20 copayment for the dermatology visit.
The dermatology visit falls within the visits with a specialist benefit category. This copayment applies regardless of the extent of services you receive during the 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 dermatology visit you had on April 29, 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 January 14, 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 January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor, includes all supplies and accessories, 1 month supply (K0553) rendered by the out-of-network (OON) provider on March 5, 2021.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item has been 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor, includes all supplies and accessories, 1 month supply (K0553) rendered by the out-of-network (OON) provider on March 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy
in a SNF setting. The Plan states the services you require are called custodial care. The Plan states custodial
care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the bathroom, and
eating. The Plan states custodial care is not a covered benefit under Medicare or this health plan.
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 qualify for SNF coverage. You do
not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled
services are not shown to be required to establish a maintenance program or to prevent deterioration of your
condition. Your care needs appear to be custodial and, as a practical matter, can be provided at a lower level of
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary due to quality of life as it seriously jeopardizes their ability to regain maximum function. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee needs three (3) hours of therapy a day. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for weakness and trouble swallowing. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound of extremity veins (93970) provided on April 22, 2021.

You asked the Plan to pay for an ultrasound of extremity veins. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says the service at issue was previously approved and paid.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultrasound of extremity veins have not been met. Specifically, the Plan has documented that payment has already been made for the service at issue. Therefore, we decided that the Plan does not have to pay for an ultrasound of extremity veins (93970) provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on June 30, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you have never been charged for laboratory services in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 laboratory services provided in an outpatient hospital facility. The record shows that you received laboratory services at an outpatient hospital facility on June 30, 2021. Therefore, you are responsible to pay the allowed amount of $27.37, which is less than the $35 copayment. You have been asked to pay $27.37 for laboratory services. Laboratory services fall 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 laboratory services provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the podiatry services and the NovaFix
supply you received on July 12, 2021.
You asked the Plan to waive the cost sharing for the podiatry services and the medical supply. You say that you
believe you had met your out-of-pocket maximum for the year prior to these services. The Plan denied your
request. The Plan says you had several claims that were reprocessed, resulting in your maximum out-of-pocket
amount not being met until after the claim for these services processed.
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 podiatry services and 20% coinsurance for medical supplies.
You have been asked to pay a $35 copayment for the podiatry services and 20% coinsurance for the medical
supply. The Plan has confirmed that due to the reprocessing of some claims, you had not yet met your annual
out-of-pocket maximum at the time of these 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 cost sharing for
the podiatry services and the NovaFix supply you received on July 12, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November 15, 2021, forward.
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that you would like a continued inpatient psychiatric stay to be covered. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary because the records received show that your condition has improved, and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric admission. Our reviewer says that a continued inpatient psychiatric admission from November 15, 2021, forward is not medically necessary. Our physician reviewer found that you did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. It appears that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission, you do not meet the criteria for continued acute inpatient mental health treatment from November 15, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety. 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 continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November 15, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus.

You asked the Plan to pre-approve Tacrolimus. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus.

Benefits for Tacrolimus may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) 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 office visit (99203) rendered by the out-of-network (OON) provider on June 1, 2021.