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

We decided that the Plan does not have to pay for the laboratory services provided on October 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 laboratory testing 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 provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria are met. 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 RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the request exceeds the utilization criteria of the LCD and therefore, the request is deemed 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 20, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for podiatry services you received on June 15, 2021, and August 17, 2021.
You asked the Plan to waive the copayments for the podiatry services. You say that you think you should be refunded these copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for the June 15, 2021, date of service ($20.91) is less than your copayment obligation, you are responsible for the full allowed amount for this service. The doctor's office did note that you have a refund on your account with them of $14.09, and you will be receiving that directly from the doctor's office.
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 podiatry services.
You have been asked to pay a $35 copayment per visit for the podiatry 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 copayments for podiatry services you received on June 15, 2021, and August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the chest (71250) provided on April 14, 2021.
You asked the Plan to waive the copayment for CT scan. You say that the services should be covered as they were done to follow up on a covid-19 related issue. 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 $150 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $111.26 copayment for a CT scan of the chest, which is less than the $150 stated in the Plan's contract. The Plan's guidelines state that cost sharing is only waived when the tests performed are reasonable in helping rule out Covid-19. CT scans fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the chest (71250) provided on April 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a neurobehavioral specialist on July 22, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you do not think you should have to pay a copayment for a two-minute phone call. 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 $40 copayment for telehealth visits with a specialist. You have been asked to pay a $40 copayment for the telehealth 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 telehealth visit you had with a neurobehavioral specialist on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy of liver services coded 47100 provided on June 9, 2021.
You asked the Plan to pay for the biopsy of liver services. 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 47100 is biopsy of liver, wedge.
We find that CPT code 47100 is not supported in the medical record. Specifically, the operative report did not include documentation of a wedge biopsy of the liver; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the biopsy of liver services have not been met. Therefore, we decided that the Plan does not have to pay for the biopsy of liver services coded 47100 provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria have not been met.
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 genicular nerve radiofrequency
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the review has determined that the requested genicular
nerve radiofrequency ablation of the right knee 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 genicular nerve radiofrequency ablation have not been met. Therefore, we
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine procedure called the Minuteman procedure.
You asked the Plan to pre-approve the Minuteman procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 Minuteman procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the minuteman procedure and device is experimental. More research is needed to show safety and efficacy. 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 Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a spine procedure called the Minuteman procedure
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the chest x-ray you had on July 19, 2021.
You asked the Plan to waive the deductible for the chest x-ray. You say that you had preoperative testing done,
but the hospital didn't send the results. So, you said that you had to have the testing done again. You do not
think you should have to pay for the repeat testing. The Plan denied your request. The Plan says you had not
met your deductible at the time of this service.
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 diagnostic imaging services.
The x-ray falls within the benefit category diagnostic imaging services benefit category. The Plan has followed
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to diagnostic
imaging services. This deductible applies regardless of the reason for the services. This cost sharing is a
contractual obligation that had not been met at the time the chest x-ray was received on July 19, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for the chest x-ray you had on July
19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the eye exam provided on July 12, 2021.
You asked the Plan to fully pay for the eye exam. You say that you used a network provider, but the bill is not
paid. You say that you should not have to ask if every doctor is in-network and the denial is unfair. The Plan
denied your request. The Plan says the claim reprocessed to only apply a $30 copayment for the eye exam. You
will not be responsible to pay any amount for refraction services to the provider.
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 $30
copayment for Medicare covered vision services at an in-network specialist's office.
You have been asked to pay a $30 copayment for the eye exam. The eye exam falls within the "Vision care"
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 fully pay for the eye exam provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on November 24, 2020.
You asked the Plan to pay for drug testing. You say that this testing was performed in the laboratory. The Plan denied your request. The Plan says this testing must be billed with the place of service where the sample was obtained.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on November 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from June 25,
2020, to July 20, 2020, and billed with code OIPE1.
You asked the Plan to pay for SNF care. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF Patient-
Driven Payment Model (PDPM) prospective payment system (PPS). Under this system, each digit of the
Health Insurance Prospective Payment System (HIPPS) code corresponds to a different case-mix group aspect
of the SNF care provided.
We looked at the file and Medicare rules. The records do not support the billing of a Clinically Complex
nursing-case mixed group. While the records show that the enrollee had a surgical incision, they do not show
that any wound care was provided. The records only indicate that the wound was monitored and the dressings
were checked. 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 pay for skilled nursing facility (SNF) care
provided from June 25, 2020, to July 20, 2020, and billed with code OIPE1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a conductive garment (E0731) provided to the enrollee on May 6, 2021.
You asked the Plan to pay for the conductive garment. You say that this claim should be paid. The Plan denied your request. The Plan says while the TENS unit will be paid for, the enrollee does not meet the criteria required for the conductive garment.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for a conductive garment. Based on the records provide, the enrollee does not meet the criteria as stated in the Medicare rules. Therefore, we decided that the Plan does not have to pay for a conductive garment (E0731) provided to the enrollee on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on March 24, 2021, by an out-of-network provider.
You asked the Plan to pay for an oxygen concentrator. You say that as a member you can purchase and pay for any equipment for your health from any legitimate provider. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 an oxygen concentrator (E1390) provided on March 24, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a patient lift (E0630) provided on May 7, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for a patient lift. You say that the requested item is a medical necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a patient lift (E0630) provided on May 7, 2021, by a supplier not enrolled in the Medicare program
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 17, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee's care. 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 June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the flow cytometry services provided on June 16, 2021.
You asked the Plan to pay for the flow cytometry services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 flow cytometry services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The documentation did not contain a signed physician order. In addition, there are no authenticated medical records from the ordering provider documenting the treating physician had intended the clinical diagnostic test be performed. Therefore, we decided that the Plan does not have to pay for the flow cytometry services provided on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on July 10, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the appropriate modifier was not used in this case.
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 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 imaging services (procedure code 70450) provided to the enrollee on July 10, 2021.