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

 We decided that the Plan does not have to reduce the copayment for the outpatient surgery services you received from May 7, 2021, to May 12, 2021.  You asked the Plan to reduce the copayment for the outpatient surgery services. You say that you were in the hospital overnight, so you should only have to pay the $250 inpatient copayment. The Plan denied your request. The Plan says you were not admitted to the hospital as an inpatient, so this copayment was charged 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 $350 copayment for outpatient surgery in an outpatient hospital facility.    You have been asked to pay a $350 copayment for the outpatient surgery services. We looked at the medical records from this stay. According to the hospital's coding summary page in your records, this stay was an outpatient observation stay, not an inpatient hospital stay. You can be an outpatient even if you spend the night in the hospital. 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 reduce the copayment for the outpatient surgery services you received from May 7, 2021, to May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a stent placement procedure performed on October 6, 2021.  You asked the Plan to waive the copayment for the stent placement. You say that you were informed that everything was approved and covered. The Plan denied your request. The Plan says you have been 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 $300 copayment for outpatient surgery at a hospital outpatient facility.   You have been asked to pay a $300 copayment for the stent placement.   The stent placement 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 a stent placement procedure performed on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Procrit.  You asked the Plan to pre-approve Procrit. You say that Procrit is medically appropriate and necessary, and should be covered. The Plan denied your request. The Plan says the medical information provided does not provide documentation of meeting criteria.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Procrit. Our reviewer says that Procrit is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of Epoetin alpha-epbx (Retacrit) before they will approve the requested drug, Procrit. Our reviewer found that the patient has not tried and failed the required drug(s). In addition, the records do not document the patient's current ferritin or transferrin saturation levels. Our physician reviewer also found that there is no indication that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an implant supported crown (D6065) provided by a participating provider on September 22, 2021.  You asked the Plan to pay for a custom fabricated abutment and an implant supported crown. You say that you do not understand why a crown over a regular tooth is covered but a crown over an implant is not. The Plan denied your request. The Plan says the dental services that were provided are not covered benefits.  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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an implant supported crown (D6065) provided by a participating provider on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided on October 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the genetic testing. 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for genetic testing provided on October 14, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 19, 2021.  

You asked the Plan to waive the copayment for the urgent care visit. You say that it was your understanding that coronavirus tests were covered. The Plan denied your request. The Plan says you have been 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 $55 copayment for each urgent care provider visit.   

You have been asked to pay a $55 copayment for the urgent care visit. Please note that you were not charged for the test itself. The urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI (magnetic resonance imaging) of a lower extremity joint (73721).

You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had sufficient conservative treatment.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

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 an MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the enrollee has not has a six-week trial of physical therapy for her knee pain. There are no red flags necessitating an MRI at this time. More conservative measures are needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI (magnetic resonance imaging) of a lower extremity joint (73721).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307, 83789-59, G0480) provided on April 2, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are 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.    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 laboratory services. Our reviewer found the provider reported CPT 80307 presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (eg, utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and CPT 83789 mass spectrometry either with or without chromatography (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, and CPT 83789 Mass spectrometry and tandem mass spectrometry (MS, MS/MS analyte not elsewhere specified, with date of service April 2, 2021. Documentation submitted was reviewed and does not meet criteria. In this case services were reported incorrectly, and therefore cannot be verified. Documentation includes a "Panel Authorization for clinical standard of care" dated April 4, 2021; urine specimen was collected on April 1, 2021; and test results dated April 2, 2021. Per Medicare guidelines, "the date of specimen collection unless the physician orders the test at least 14 days following the patient's discharge from the hospital". Documentation does not support at least 14 days following the patient's discharge from hospital. Therefore, this service was incorrectly reported. Also, for CPT 83789, documentation supported this code was provided for validity testing. Per CMS, this would not be billed separate from drug testing. Providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. Furthermore, our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between G0480 and G0483. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair.  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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307, 83789-59, G0480) provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the provision of INR test supplies provided on September 20, 2021.  

You asked the Plan to waive the copayment for the INR test supplies. You say that you were only billed a 20% coinsurance in the past instead of the specialist copayment. The Plan denied your request. The Plan says you have been 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 $45 copayment for specialist services. Please note that the Medicare Claims Processing Manual states that the test or supplies is not covered as durable medical equipment (DME). It is covered under the physician fee schedule.   

You have been asked to pay a $45 copayment for the INR test supplies. The INR test supplies fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 provision of INR test supplies provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for home health services for the enrollee.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available for these services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 an out-of-network referral for home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on October 21, 2021.  You asked the Plan to pay for the outpatient clinic visit. You say that the medical records support the medical necessity of the service and payment should be reconsidered. The Plan denied your request. The Plan says the out-of-network service was not authorized.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for hearing aid repair services provided on October 21, 2021.  You asked the Plan to pay for hearing aid repair services. The Plan denied your request. The Plan says that the Plan has paid the hearing aid repair services at $150.00 and left $150.00 member responsibility.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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 the Plan has paid the maximum hearing aid benefit amount. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aid repair services provided on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.  You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have achieved the maximum benefit of this level of care.  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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant and cooperative with treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bilateral extremity angiography rendered on July 30, 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 75716 (radiological supervision and interpretation of bilateral extremity angiography) and 37225 (endovascular revascularization). Code 75716 is a column II code with a modifier indicator of 1 when billed with column I code 37225. Code 75716 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 bilateral extremity angiography rendered on July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting.  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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19 on the heels of a prior prolonged hospitalization. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.  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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that your specialist stated custom made inserts would work best for your flat feet. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; brachial plexus (CPT code 64415-59-LT) provided on June 23, 2021.  You asked the Plan to pay for the injection. 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 states this code is included in CPT code 01630; therefore, it cannot be separately reimbursed. The Plan states the documentation received did not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. The Plan states the submitted documentation does not support that the service was performed at the request of the surgeon for post-operative pain management.  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 injection. Our reviewer found the provider reported CPT 64415 injection(s), anesthetic agent(s) and/or steroid; brachial plexus. Documentation submitted was reviewed and does not meet criteria. Procedure report does not support injection was given for post op pain, and therefore this procedure cannot be confirmed as not part of the anesthesia.  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 injection have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; brachial plexus (CPT code 64415-59-LT) provided on June 23, 2021.