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

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550, 83970, 84100) provided to the enrollee on August 4, 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 covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CMS consolidates into 
dialysis services the laboratory testing related to the treatment of ESRD. CMS allows only dialysis facilities to 
report ESRD-related laboratory tests and includes reimbursement for laboratory testing in dialysis. The 
documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to 
treatment of ESRD. Therefore, in accordance with CMS, the laboratory tests are the responsibility of the 
dialysis center and are not separately reportable by the laboratory. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, 83970, 84100) provided to 
the enrollee on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Magnetic resonance imaging (MRI) provided on May 17, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an MRI on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an MRI on May
17, 2021. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the Outpatient diagnostic tests 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 Magnetic resonance imaging (MRI) provided on May 17, 2021.
Your complaint about the first MRI being misread, which led to the second MRI, is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and the x-rays 
provided on August 5, 2021.

You asked the Plan to waive the copayments for the specialist office visit and the x-rays. You say that the 
services were not rendered. The Plan denied your request. The Plan says you have been asked to pay 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 $35 
copayment for medical care or surgery services in a specialty physician's office and a $35 copayment for each 
Medicare-covered x-ray. 

You have been asked to pay a $35 copayment for the specialist office visit and a $35 copayment for the x-rays. 
The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 
benefit category. The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 
benefit category. The medical record shows the services were rendered.

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 the specialist office visit and the x-rays provided on August 
5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on April 7, 2021.

You asked the Plan to pay for laboratory services. You say that these codes should be paid. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 11, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. The records do not indicate the enrollee's specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for MRI's provided on July 17, 2021.

You asked the Plan to waive the copayments for MRI's. You say that you already paid the $150 copayment and are receiving a bill for additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for MRI's. 

The record shows that you received two MRI's on July 17, 2021. Therefore, you are responsible to pay a $150 copayment per each MRI. However, you are being asked to pay the total amount of $296.33, which is less than the total copayment amount.

You have been asked to pay the total amount of $296.33 for MRI's. MRI's 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 copayments for MRI's provided on July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (CPT code 64494) provided to the enrollee on August 17, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 64494 was not billed in accordance with Medicare National Correct Coding Initiative Policy -Medically Unlikely Edits (MUE). This is not a medical necessity denial. We determined that our original decision to deny payment is correct. CPT code 64494 has an MUE value of 1, but billed 2 units. Per the above guidelines, we find the Medicare rule for payment of this date of service August 17, 2021 claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (CPT code 64494) provided to the enrollee on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow (Q4206).
You asked the Plan to pre-approve fluid flow. The Plan denied your request. The Plan says orthopedic uses for this injection are considered investigational and experimental.
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 fluid flow (Q4206). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that a fluid flow injection for this condition is considered experimental. Our reviewer says that 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 fluid flow have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow (Q4206).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services (88305-59) provided on February 22, 2021.  You asked the Plan to pay for pathology services. You say that this should be covered. The Plan denied your request. The Plan says this is not supported as a distinct service.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records show that this was performed as part of the biopsy billed with G0146. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88305-59) provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for durable medical equipment 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 this is a network lock-in, and medically necessary care is available in-network.  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 durable medical equipment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting provided on September 3, 2021.

You asked the Plan to pay for the contact lens fitting. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says contact lens fittings are not covered by Medicare or the Plan's supplemental vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear 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 Plan excludes coverage of contact lens fittings. Therefore, we decided that the Plan does not have to pay for the contact lens fitting provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on July 19, 2021.
You asked the Plan to pay for the services provided. You say that the test monitors for recurrence of bladder cancer. The Plan denied your request. The Plan says the test is not covered by Medicare.
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. We looked at the file and the rules. The records provided do not show that the testing was ordered due to signs and symptoms, or for the treatment of a specific medical problem. The services provided were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract removal rendered on June 16, 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 claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that the physician providing the remaining postoperative care must show the date care was assumed in Item 19 on the paper Form CMS-1500. 

We looked at the file and Medicare rules. The file shows that the surgeon billed both the -54 and -55 modifier, signifying some post-operative care was provided; however, this is not documented on the CMS-1500 claim form as required. 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 pay for the cataract removal rendered on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (CPT code 81291) provided to the enrollee on April 16, 2021.  

You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not a covered benefit.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. CPT 81291 MTHFR (5,10-methylenetetrahydrofolate reductase) gene analysis, is a Medicare non-covered service. Therefore, we decided that the Plan does not have to pay for MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (CPT code 81291) provided to the enrollee on April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on July 10, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell outside 
your house and hit your head and an ambulance was called because there was blood coming down the side of 
your face. You say that you were not transported to the hospital because your head was not bleeding, and you 
said you were okay. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport 
benefit and if no transport of a Medicare beneficiary occurs then there is no Medicare-covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. 

The ambulance company did not provide transport services on July 10, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on July 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing (81479) provided on July 16, 2021.

You asked the Plan to pay for GeneSight testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician.

We looked at the file and Medicare rules. Although there is an order in the file, it is not signed. Based on this 
information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Therefore, 
we decided that the Plan does not have to pay for GeneSight testing (81479) provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 18, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim indicates a place of service as an independent laboratory. The records do not show that the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 
     
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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.