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

 We decided that the Plan does not have to pre-approve breast ultrasound (76645) screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed (77067) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the diagnostic services. You say that you have had your mammograms done at this facility for the last 25 years. You trust the radiologist who reviews the mammograms and prefer to have the same radiologist again. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 breast ultrasound (76645) screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed (77067) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
September 21, 2021, through September 30, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $295 
copayment each day, for days 1-5 and a $0 copayment per day, for days 6-90, for inpatient hospital care. 
You have been asked to pay $1,475 ($295 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from September 21, 
2021, through September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (64447) provided August 6, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not separately payable.
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 code 64447 is not supported in the medical record. Specifically, the code billed is included in the primary procedure (01400). 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 anesthesia services (64447) provided August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 12, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as a wellness visit. 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 $15 copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $15 copayment for an office visit. The record indicates that these services were billed as a clinic visit as the attending provider is an internal medicine specialist and the provider advised you beforehand that it would not be considered a wellness 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 an office visit provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on October 13, 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 telehealth 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 service provided in this case was a telehealth office visit rendered by an out-of-network provider. The Plan contract states that an enrollee has the option of getting covered services through an in-person visit or by telehealth. If the enrollee chooses to get one of these services by telehealth, they must use a network provider. 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 (99214) rendered by the out-of-network (OON) provider on October 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (75710) provided June 7, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is inclusive to another code billed and not separately 
payable.
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 code 75710 is not supported in the medical record. Specifically, this code is inclusive to CPT 
code 37246 which was also billed and paid. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiology services (75710) provided June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two retainers (D6545 x2) and pontic (D6245) provided on June 15, 2021.
You asked the Plan to pay for the retainers and pontic. You say that bridges are expected to last 15 years where partials only last about 5 years. You also say that your plan covers partials, but you are hoping they agree that a bridge is a better choice. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.
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 the two retainers (D6545 x2) and pontic (D6245) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spinal injection provided on October 25, 2021.  You asked the Plan to pay for the spinal injection. You say that this treatment is considered necessary for this enrollee's condition. The Plan denied your request. The Plan says no records were submitted to support medical necessity.  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. No medical records were included in the file. As such, it cannot be confirmed whether coverage criteria are met. Based on this information, we decided that Medicare rules for coverage of the spinal injection have not been met. Therefore, we decided that the Plan does not have to pay for the spinal injection provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 11, 2021.
You asked the Plan to pay for procedure code 62320. You say that you billed this service correctly and it should be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the Plan has requested medical records from you multiple times to show that these services were appropriate. To date, you have not provided these records. Without this documentation, neither the Plan nor our organization can determine the appropriateness of these services.
Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. The Plan denied your request. The Plan says the 
records do not show subluxation.
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 services Our reviewer says 
that the requested chiropractic services are not medically reasonable and necessary. Our physician reviewer 
found that the record indicates that the enrollee has hip pain after jumping down from the bed of a pickup truck. 
The record does not indicate that the enrollee has a spinal 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR testing provided on October 8, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that urine PCR amplification techniques raise considerable concerns regarding contamination from one
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results
may also be challenging. Amplification of organisms representing latent infection or colonization cannot be
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally,
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large
groups of patients for many of the microorganisms.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the urine PCR testing provided on October 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 improving and should only require short-term additional acute care services including basic wound care that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.
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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care (99284) provided on April
21, 2021.
You asked the Plan to waive the copayment for the emergency care. 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 $90
copayment for Emergency care.
You have been asked to pay a $90 copayment for emergency care. Based on your contract with the Plan, costsharing for emergency care visits is only waived if you are admitted to the hospital for the same condition
within 24 hours of the 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 emergency care (99284)
provided on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says the requested inpatient psychiatric care does not meet criteria.
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 care. Our reviewer says that the service is not medically necessary. Our physician reviewer found you were compliant and cooperative with treatment. You do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 23, 2022 forward. You could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors while being cooperative and compliant. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 6, 
2021.
You asked the Plan to pay for procedure code 62320. You say that this service was billed correctly and should 
be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide 
medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. In this case, the Plan has requested medical records from you multiple times to show 
that these services were appropriate. To date, you have not provided these records. Without this 
documentation, neither the Plan nor our organization can determine the appropriateness of these services. 
Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of 
service September 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening services (81404, 81442 and 81419) provided on June 1, 2021.
You asked the Plan to pay for the cardiovascular disease screening. You say that you would like reconsideration because this testing was ordered by the member's treating physician. The Plan denied your request. The Plan says cardiovascular genetic testing does not meet the Medicare definition of cardiovascular disease screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the cardiovascular disease screening, 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 cardiovascular disease screening services (81404, 81442 and 81419) provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus genetic testing (81295, 81298, 81317, 81402, 81162, 81191, 81309, 81292, 81321) provided on April 13, 2021.
You asked the Plan to pay for Tempus genetic testing. You say that this should be covered as a network benefit. The Plan denied your request. The Plan says this was not billed correctly.
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 Tempus genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Tempus genetic testing (81295, 81298, 81317, 81402, 81162, 81191, 81309, 81292, 81321) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous process decompression system (22869,
22870).
You asked the Plan to pre-approve the outpatient procedure. You say that you strongly believe that coverage
should be provided under the enrollee's Plan which is based on the guidelines that they must comply with
Original Medicare regulations. The Plan denied your request. The Plan says this procedure is considered
investigational and therefore is not a covered benefit. There is insufficient evidence of its effectiveness.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient procedure have not been met. Therefore, we decided that the Plan does not have to
pre-approve interspinous process decompression system (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on September 28, 2021.
You asked the Plan to pay for foot orthotics. You say that 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 pay for foot orthotics provided on September 
28, 2021.