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

 We decided that the Plan does not have to pay for the physician visit and surgery services provided on September 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the physician visit and surgery services. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the physician visit and surgery services provided on September 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chiropractic care (98940).  You asked the Plan to pre-approve chiropractic care. You say that this is medically necessary. The Plan denied your request. The Plan says you are not improving.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   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 chiropractic care Our reviewer says that the requirements for coverage of chiropractic care have not been met. Our physician reviewer found the record indicates that you have muscle spasms and sciatica. There is no documentation of the presence of a subluxation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic care (98940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for contact lens fitting provided on October 22, 2021.  You asked the Plan to pay for contact lens fitting. The Plan denied your request. The Plan says contact lens fitting is not a covered benefit.  Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case  We looked at the file and the Plan's rules. The file shows that contact lens fitting is not a covered benefit. Therefore, we decided that the Plan does not have to pay for contact lens fitting provided on October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the osseous surgery, 4 contiguous teeth per quadrant (D4260), and the osseous surgery, 1 to 3 contiguous teeth per quadrant (D4261) provided on October 6, 2021.  You asked the Plan to pay for the dental services. You say that you were not informed about the exclusion of dental coverage. You say that you feel these services should be covered. You also say that your dentist said these services were necessary. The Plan denied your request. The Plan says the osseous surgery is not listed as covered services.  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, osseous surgery is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery, 4 contiguous teeth per quadrant (D4260), and the osseous surgery, 1 to 3 contiguous teeth per quadrant (D4261) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99204) provided on July 8, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for a specialist office visit. You say that this provider was asked to offer an opinion in a report and initiated a diagnostic and therapeutic services during the same visit based on the patient's condition, therefore, meeting the requirements for a consultation. The Plan denied your request. The Plan says there is no referral letter from an in-network physician and this provider is not part of the health plan. The Plan also services that the services were not medically necessary.  

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 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 a specialist office visit (99204) provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided on July 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay more for the periodic oral evaluation, bitewings, and prophylaxis. You say that when you took out this policy you were advised the Plan would cover your dental appointment and cleaning. You also say that the Plan you have is supposed to cover any doctor and you would like these services to be paid. The Plan denied your request. The Plan says these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 are responsible for a 50% coinsurance for each of these services, plus the difference between the billed amount and allowed amount because the services were received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110) provided on July 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the astigmatism correcting function of an intraocular lens (V2787) provided on August 4, 2020.  You asked the Plan to pay for astigmatism correcting function of an intraocular lens. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is not covered by Medicare.  The Plan covers all items that Medicare covers.   Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL.   While an A-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism correcting function of an intraocular lens (V2787) provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 your medical condition appear to be generally stable on outpatient medications with no issues that require a physician's evaluation three or more times per week. You do not require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the long-term care facility with part time therapy appears to be 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the cytopathology by florescence in situ hybridization (FISH) testing provided on March 25, 2021, billed with code 88120.  You asked the Plan to pre-approve the FISH testing. You say that this is a medically necessary test to evaluate bladder health. The Plan denied your request. The Plan says this is a noncovered screening test.  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 FISH testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with stress incontinence. No other clinical information was provided. There is no documentation of signs/symptoms of bladder cancer. This testing is not indicated as a screening test for bladder cancer.   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 FISH testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the cytopathology by florescence in situ hybridization (FISH) testing provided on March 25, 2021, billed with code 88120.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for to pay for procedure code 70450 billed for date of service October 5, 2021.  

You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says this code is bundled with code 70496.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code procedure code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for to pay for procedure code 70450 billed for date of service October 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional psychological testing.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says additional hours are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has a diagnosis of an unspecified mental disorder due to known physiologic condition. The Plan approved 8 hours of neuropsychological testing. There is no documentation to the excessive testing hours requested.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional psychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the intravitreal injections (67028) provided on July 21, 2021, and August 30, 2021.  You asked the Plan to waive the copayment for the intravitreal injections. You say that the services should be covered. 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 $350 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a $700 copayment for two intravitreal injections. Intravitreal injections fall within the Outpatient Surgery and Other Medical 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 intravitreal injections (67028) provided on July 21, 2021, and August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 01992 provided on June 30, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an incorrect anesthesia code was billed for the surgical services rendered.  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 01992 is anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position.  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 anesthesia services. Our reviewer says that the documentation does not support payment for the anesthesia services as billed. Our reviewer found the Plan states CPT 64640 Destruction by Neurolytic Agent, intercostal nerve was the procedure for anesthesia services provided. Anesthesia report documents services were performed for "B/L suprascapular nerve ablation." Anesthesia report describes general anesthesia. Documentation is not clear on what CPT 01992 being billed for, an injection or general anesthesia, and in this case cannot be verified.  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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01992 provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you had at an outpatient hospital facility on October 6, 2021.  You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay for check-ups before. 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 $25 copayment for lab services at an outpatient hospital facility.   You have been asked to pay a $25 copayment for the lab 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 lab services you had at an outpatient hospital facility on October 6, 2021.   Please note that this decision is only related to the cost sharing charged for lab services.  If you wish to dispute any other charges, that will need to be addressed by your health plan directly
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infusion supplies (A4221, K0455 and J3285) provided on October 18, 2019, through November 16, 2019.  You asked the Plan to pay for the infusion supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a valid Proof of Delivery.  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 for the supplies provided in this case. Specifically, the documentation does not note the actual date that the supplies were delivered and does not include an enrollee signature. 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 the infusion supplies (A4221, K0455 and J3285) provided on October 18, 2019, through November 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rocklatan eye drops.  You asked the Plan to pre-approve Rocklatan. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.    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 Rocklatan eye drops.   Benefits for Rocklatan 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the EEG; including recording awake and drowsy (CPT code 95816-26) provided to the enrollee on March 15, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  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 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 service. Our reviewer found the differential included stroke and seizure. Magnetic resonance imaging (MRI) showed areas of the brain that appeared to be likely acute/subacute infarcts. The enrollee was placed on anticoagulation. EEG; including recording awake and drowsy (CPT code 95816-26) provided to the enrollee on March 15, 2021. Although the provided documentation refers to EEG results being reviewed, the actual report from the EEG from March 15, 2021, was not provided in the documentation. Therefore, without sufficient objective evidence of EEG being performed for the enrollee on March 15, 2021, it will be considered not supported.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for the EEG; including recording awake and drowsy (CPT code 95816-26) provided to the enrollee on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 2, 2021.  

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not received.  

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   

We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider for the date of service in question. Without records, it cannot be determined that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 2, 2021.