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

We decided that the Plan does not have to pay for lab services (80053, 36415, 82306, 80061) provided on July 24, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (80053, 36415, 82306, 80061) provided on July 24, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427 and A0425),
provided on July 17, 2021.
You asked the Plan to waive the copayment for the ambulance service. You say that you should not have to pay
a cost share. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290
copayment for ambulance services.
You have been asked to pay $261.85 out of the $290 copayment for the ambulance service. This service falls
within the ambulance 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 ambulance service (A0427 and A0425),
provided on July 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PBRT (CPT code 77523), for the enrollee.

You asked the Plan to pre-approve the PBRT. You say that the service is medically necessary. The Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the standard of care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial. The Plan states a review of the current medical literature indicates that the standard of care for radiation therapy for prostate cancer is standard radiation therapy including Intensity modulated radiation therapy (IMRT).

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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the decision is unfavorable as the services are not medically necessary based on Medicare criteria. 

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 PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve PBRT (CPT code 77523), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing services provided on May 28, 2021.

You asked the Plan to pay for the testing services. You say that the testing was a valuable tool in determining treatment for the enrollee. The Plan denied your request. The Plan says the enrollee does not have a major depressive disorder.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications.

We looked at the file, and Medicare rules. The provided pharmacogenetic testing was reportedly ordered to make decisions about the patient's medications. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a response to medication. In this case, there are insufficient medical records to support the provided testing was ordered based on the enrollee's response to medications. 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 GeneSight testing services provided on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625) provided to the enrollee on February 23, 2021.

You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied your request. The Plan says radiofrequency ablation used for SI joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested service is 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 service have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625) provided to the enrollee on February 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 14, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's
attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a lens (V2783), provided on January 12, 2021.
You asked the Plan to pay for a lens. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.
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. Additional lens options including, but not limited to, Deluxe, Premium or Platinum progressive lenses, blended bifocal, Hi Index, tinting, scratch coating, UV or anti-reflective coating, and polycarbonate are not covered. We looked at the file and the Plan's rules. The code V2783 is for the Hi-Index material upgrade and is not a covered benefit for you. Based on this information, we decided that the Plan's rules for coverage of a lens have not been met. Therefore, we decided that the Plan does not have to pay for a lens (V2783), provided on January 12, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PDN services (CPT code(s): S9124 and S9123), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services of a private duty nurse or other private duty attendant are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The services are not covered by Medicare or the health plan. Medicare guidance says status code "I" Not valid for Medicare purposes.

Medicare uses another code for reporting of and payment for these services. Therefore, we decided that the Plan does not have to pre-approve PDN services (CPT code(s): S9124 and S9123), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy (45380), provided on September 20, 2021.

You asked the Plan to waive the copayment for the colonoscopy. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for services provided at an outpatient hospital or ambulatory surgical center. 

You have been asked to pay a $100 copayment for the colonoscopy. This service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy (45380), provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), drugs or medicaments
dispensed in the office for home use (D9630), guided tissue regeneration (D4266), bone replacement graft for
ridge preservation (D7953), and gingival flap procedure (D4241) of the upper right quadrant or pay more for
the problem focused limited oral evaluation (D0140) provided on March 10, 2021 by an out-of-network (OON)
provider.
You asked the Plan to pay for the preventive procedure, drugs or medicaments, guided tissue regeneration,
bone replacement graft, and gingival flap procedure, and to pay more for the problem focused limited oral
evaluation. You say that you would like to be at least partially reimbursed since these services were rendered
due to an infection. The Plan denied your request. The Plan says the treating provider does not have a contract
with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their
billed amount to you. The Plan also says that the preventive procedure, drugs or medicaments, guided tissue
regeneration, and bone replacement graft are not covered services, and you have exhausted your benefits for the
gingival flap procedures.
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 preventive procedure (D1999),
drugs or medicaments dispensed in the office for home use (D9630), guided tissue regeneration (D4266), and
bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The
contract says that periodontal surgery is limited to one per quadrant every three years. The record shows that
you received a gingival flap procedure (D4241) on the upper right quadrant on December 23, 2020 and your
gingival flap procedure (D4241) for the upper right quadrant has been exhausted. You are also responsible for
the difference between the billed amount and allowed amount for covered dental services that were received
OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), drugs or
medicaments dispensed in the office for home use (D9630), guided tissue regeneration (D4266), bone
replacement graft for ridge preservation (D7953), and gingival flap procedure (D4241) of the upper right
quadrant or pay more for the problem focused limited oral evaluation (D0140) provided on March 10, 2021 by
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-network benefits for outpatient physical therapy (PT), occupational therapy (OT) and speech therapy (ST) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve in-network benefits for PT, OT and ST. You say that there is no in-network provider that can provide the same level of service that you can provide. You also say the enrollee resides in custodial care and the facility cannot directly provide rehabilitation services. The Plan denied your request. The Plan says services to an OON provider are only approved at the enrollee's in-Plan benefit level, when the service is not available through the Plan's provider network. The Plan also says that if the enrollee wishes to pursue treatment with the OON provider, the enrollee may do so utilizing her out-of-Plan benefit coverage.
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. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. The EOC confirms that the enrollee may utilize her POS benefit coverage for services with an OON provider. Therefore, we decided that the Plan does not have to pre-approve in-network benefits for outpatient physical therapy (PT), occupational therapy (OT) and speech therapy (ST) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 6, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 23, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on August 6,
2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for
the services rendered.
The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to
the services of a physician/NPP also must meet all incident-to requirements.
We find that CPT code 97530 is not supported in the record. Specifically, the record shows that this claim was
billed by a nurse practitioner and the services were rendered by an occupational therapist. A nurse practitioner
cannot bill for the services of an Occupational Therapist. Based on this information, we decided that Medicare
rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not
have to pay for the therapeutic activities (97530) provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a denosumab 1mg injection (J0897) provided on August 31, 2021.

You asked the Plan to waive the copayment for the denosumab 1mg injection. You say that the services should be covered as you were informed by the provider that there would be no cost-sharing for these injections. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for a denosumab injection ($1,398.54 Allowed Amount x 20% = $279.71 coinsurance). The record indicates that there were no attempts from you or the provider to verify the cost-sharing with the Plan before the services were rendered. Denosumab injections fall within the Medicare Part B prescription drugs 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 denosumab 1mg injection (J0897) provided on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case the enrollee was admitted with urosepsis and multiple stage IV pressure ulcers with osteomyelitis. The record indicates that the enrollee is improving and requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on January 22, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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 January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on January 6, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on January 6, 2021