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

We decided that the Plan does not have to pay for the respiratory and Coronavirus molecular pathogen panel provided on April 16, 2021.

You asked the Plan to pay for the respiratory and Coronavirus molecular pathogen panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 find that CPT codes 87496, 87498, 87541, 87640, 87532, and 87798 are not supported in the medical record. Specifically, the documentation indicates that more than five targets were provided. There is a more appropriate code to describe the services rendered. In addition, multiplex polymerase chain reaction respiratory viral panels of 6 or more pathogens are non-covered. Based on this information, we decided that Medicare rules for coverage of the respiratory and Coronavirus molecular pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory and Coronavirus molecular pathogen panel provided on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrothermal annuloplasty (22526).
You asked the Plan to pre-approve electrothermal annuloplasty. You say that this request is medically necessary. The Plan denied your request. The Plan says this type of procedure is not supported because research has not proven it to be helpful for your condition.
The Plan must follow Medicare rules. Medicare rules say that TIPs is not covered by Medicare for lower back pain. We looked at the file and Medicare rules. In this case, the requested procedure is not covered for your low back pain. Based on this information, we decided that Medicare rules for coverage of electrothermal annuloplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve electrothermal annuloplasty (22526).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the left heart catheterization services coded 93462 and the intracardiac echocardiography services coded 93662 provided on October 27, 2020.
You asked the Plan to pay for the left heart catheterization services and the intracardiac echocardiography 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes 93462 and 93662 are not supported in the medical record. Specifically, codes 93462 and 93662 are add-on codes. These codes were billed on the claim without an appropriate primary procedure code. Based on this information, we decided that Medicare rules for coverage of the left heart catheterization services and the intracardiac echocardiography services have not been met. Therefore, we decided that the Plan does not have to pay for the left heart catheterization services coded 93462 and the intracardiac echocardiography services coded 93662 provided on October 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dronabinol.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has locally advanced lung cancer and anorexia with weight loss. She has not tried and failed the Plan's required drug, megestrol. The records do not support that the required drug would be contraindicated or less effective; therefore, dronabinol is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve dronabinol.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure is considered safe and effective, and the enrollee is a good candidate. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on April 12, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a participating provider on February 16, 2021.

You asked the Plan to waive the copayment for specialist telehealth services. You say that you do not feel like the phone call you received warrants a copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 physician/practitioner services/in-network/specialist. 

You have been asked to pay a $40 copayment for specialist telehealth services. The correct copayment has been applied to the services that were provided. Specialist telehealth services fall within the physician/practitioner services/in-network/specialist 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 specialist telehealth services provided by a participating provider on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision and repair provided on March 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the excision and repair. You say that the services are 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 excision and repair provided on March 23, 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 additional physical therapy visits.

You asked the Plan to pre-approve physical therapy. You say that the enrollee continues to benefit from
physical therapy services. The Plan denied your request. The Plan says the requested additional physical
therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 physical therapy. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found there is no documentation that the requested therapy is generally
accepted as a specific and effective therapy for the enrollee's condition. The enrollee appears to have plateaued
with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant
improvement in the enrollee's symptoms or functional status. Further utilization of a home exercise program
appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are
required to safely and effectively provide treatment, or that the services can be safely and effectively performed
only by a therapist or under the supervision of a therapist.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4222, J2260) provided December 15, 2020 to December 21, 2020.
You asked the Plan to pay for the infusion supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed items.
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 physician order or proof of delivery. No itemized shipping invoice was provided. 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 infusion supplies (A4222, J2260) provided December 15, 2020 to December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on January 27, 2021.

You asked the Plan to pay for the MRI. 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 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 77049 is magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral.

We find that CPT code 77049 is not supported in the medical record. Specifically, code 77049 has a status indicator of "B". The edit 62 is used when a code is not recognized by the Outpatient Prospective Payment System (OPPS) and an alternate code for the same service may be available. A claim processed with an edit 62 has a disposition of return claim to provider. The claim is not eligible for payment based on billing guidelines. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have upper limb spasticity after a stroke. You have not tried and failed the Plan's required drugs, Dysport or Xeomin. The records do not show that the required drugs would be less effective or cannot be taken; therefore, Botox is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care skilled nursing services (CPT code G0299), to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that your health is deteriorating. You state the services are medically necessary for your health to improve. The Plan denied your request. The Plan says they have confirmed there is no network deficiency for your service area for the requested service. The Plan states the service can be approved if performed by an in-network provider.
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 home health care skilled nursing services (CPT code G0299), to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy services to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services in this case.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve occupational therapy services to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L1833, L2397, L2810) provided December 14, 2020.

You asked the Plan to pay for the orthosis. You say that the brace was medically necessary. The Plan denied your request. The Plan says the documentation does not support the items billed.

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 relevant medical records which support medical necessity for the supplies provided in this case. The provided records do not show that the ordering physician discussed the need for the billed items with the patient. 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 an orthosis (L1833, L2397, L2810) provided December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested service.

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 service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office
consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87798, 87641, 87500, 87640, 87798, 87633, 87581) provided May 12, 2020.

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 the documentation does not support the billed services.

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 find that CPT codes 87798, 87641, 87500, 87640, 87798, 87633, & 87581 are not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 lab services (87798, 87641, 87500, 87640, 87798, 87633, 87581) provided May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82274, 82656, 83520, 83631, and 87338 provided on June 18, 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 82274, 82656, 83520, 83631, and 87338 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82274, 82656, 83520, 83631, and 87338 provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on March 9, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you waited for hours and
you were not even seen. The Plan denied your request. The Plan says the correct copayment has been applied.
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 physician/practitioner services/in-network.
You have been asked to pay a $40 copayment for a specialist office visit. The correct copayment has been
applied to the specialist office visit that was provided. A specialist office visit falls within the
physician/practitioner services/in-network 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 specialist office visit provided by a participating provider on March 9, 2021.