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

 We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) and the needle electromyography, 2 extremities, (95861) provided from March 24, 2021, to March 25, 2021.  You asked the Plan to pay for the outpatient services. You say that this is the correct coding for the procedure that was done. The Plan denied your request. The Plan says according to the Medicare LCA, procedure codes 95938 and 95861 are not covered for the enrollee's diagnosis code, M46.1. The Plan also says that since M46.1 is not listed, it does not support medical necessity.  The Plan must follow Medicare rules. Medicare rules say that procedure codes 95938 and 95861 are medically necessary when performed as a result of specific ICD-10-CM codes.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, the record shows that the enrollee's diagnosis code, M46.1, is not listed as a covered diagnosis code. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study (95938) and the needle electromyography, 2 extremities, (95861) provided from March 24, 2021, to March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 17, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 0242U is targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements.  We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider from January 15, 2021, through June 23, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 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 chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider from January 15, 2021, through June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance (CPT code 62320).  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the service is not 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 pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a neck pain score. There is a question of a previous injection with no response documented. Not enough info is present to meet criteria for cervical epidural steroid injection (ESI).  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance (CPT code 62320).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on May 10, 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 claim was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed adjacent to the CPT code for GeneSight testing.  We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX Z-Code. 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 pay for the GeneSight testing rendered on May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on January 2, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says no prior authorization was obtained by the provider prior to rendered services and prior authorization is required for out-of-network services to be rendered if services are not urgent or emergent in nature.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   The contract with the Plan says that prior authorization is required for non-emergency ambulance transportation. The contract with the Plan also 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.  We looked at the file, the Plan's rules and Medicare rules. The file shows that non-emergency ambulance services require prior authorization to determine if the services are medically necessary or urgent and emergent with a non-contact provider. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on January 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on June 1, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that this was supposed to be the yearly free exam, x-ray, and cleaning. You say that you shouldn't have to pay because you are on a fixed income and can't help having to change dentists. The Plan denied your request. The Plan says reimbursement for one comprehensive oral evaluation was already issued.  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, you also have a maximum benefit of one comprehensive oral evaluation every three calendar years. The Plan paid for the comprehensive oral evaluation provided on March 7, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on June 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services, therapeutic, prophylactic, or diagnostic injection, Haloperidol injection, and insulin injection provided on May 28, 2021.  You asked the Plan to pay for the laboratory services, therapeutic, prophylactic, or diagnostic injection, Haloperidol injection, and insulin injection. You say that this patient was discharged to hospice. You also say that the patient was not in hospice during this service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services, therapeutic, prophylactic, or diagnostic injection, Haloperidol injection, and insulin injection provided on May 28, 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 a surgeon on May 13, 2021.  You asked the Plan to waive the copayment for the office visit with a surgeon. You say that you should not have to pay this copayment because it was needed because of two failed antibiotics. 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 $35 copayment per visit for specialist visits.   You have been asked to pay a $35 copayment per visit for the office visit with a surgeon. The office visit with a surgeon falls within the specialist visits benefit category. This copayment applies regardless of the reason for 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 office visit you had with a surgeon on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the consultation (CPT code 99204) to be provided by out-of-network providers.  You asked the Plan to pre-approve the out-of-network services. You say that you are in need for surgery that the provider specializes in. The Plan denied your request. The Plan says this provider is not in-network with your plan and there are network providers that can provide the services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the consultation (CPT code 99204) to be provided by out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a right carotid stent.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate that the enrollee has symptomatic carotid artery stenosis and asymptomatic carotid artery stenosis greater than or equal to 80%.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a request is made for authorization for PTA and stent placement to address an asymptomatic, 74% narrowing in the right internal carotid artery. The guidelines are clear that such a procedure would be authorized only if there were accompanying symptoms, or if the lesion narrowing were 80% or more. In their absence, this request would not be considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a right carotid stent.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for shingles vaccination provided on April 8, 2021.  You asked the Plan to pay for shingles vaccination. You say that you were told that preventive care would be covered and paid. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this immunization is not covered by Medicare Part B and should be covered by your Medicare Part D benefits instead.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccination. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to shingles vaccination. Therefore, we decided that the Plan does not have to pay for shingles vaccination provided on April 8, 2021.   Benefits for shingles vaccination 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a nebulizer (E0570) provided on December 21, 2020.

You asked the Plan to pay for a nebulizer. You say that this was medically necessary. The Plan denied your request. The Plan says required documentation has not been submitted.

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 proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. 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 nebulizer (E0570) provided on December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ultrasound, abdominal, real time with image documentation; complete (76700) provided June 14, 2021.

You asked the Plan to waive the deductible for the ultrasound. You say that you would like the services processed as in-network. The Plan denied your request. The Plan says the enrollee had not yet met her deductible at the time of service and therefore the cost of the service was correctly applied to the deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to certain services including outpatient diagnostic tests and therapeutic services and supplies. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on June 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound, abdominal, real time with image documentation; complete (76700) provided June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on June 9, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the complete maxillary and mandibular dentures. You say that you went to a licensed dentistry. You also say that you did not get a referral because you did not think you had to have a referral to see a specialist. The Plan denied your request. The Plan says the services in question were provided by a dental provider who is opted out of Medicare.  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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on June 9, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the extraction (D7210), retainer crowns (D6740 x 2), pontic (D6245), nitrous oxide (D9230), and sales tax (D9985) provided on July 15, 2021.  You asked the Plan to reimburse you for the dental services. You say that you were in New Mexico when you started experiencing intense pain in your mouth. You say that the services were an emergency. You also say you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services provided by a dentist that has opted out of Medicare.  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, dental services provided by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the extraction (D7210), retainer crowns (D6740 x 2), pontic (D6245), nitrous oxide (D9230), and sales tax (D9985) provided on July 15, 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 you need physical and occupational rehabilitation due to your medical condition (amputation) to return to normal function state. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your needs may be met at a lower level of care, such as, at home with supervision and home health services or at an assisted living facility with home health services. The Plan states your needs can also be met in a long-term facility with part-time skilled services.  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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for services you had with an out-of-network cardiologist on May 5, 2021.  You asked the Plan to waive the deductible for the out-of-network cardiology services. You say that your primary care doctor referred you to a cardiologist for a stress test.  You arrived late to the cardiologist's office, so the doctor to whom you had been referred was not available to see you.  You stated that you were seen by another doctor in the office.  You stated that you were not aware that this other doctor was not in your network. The Plan denied your request. The Plan says this deductible was appropriately applied to these out-of-network services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible which applies to out-of-network cardiology services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to out-of-network cardiology services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network cardiology services was received on May 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for services you had with an out-of-network cardiologist on May 5, 2021.