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

We decided that the Plan does not have to pay for laboratory services provided on July 26, 2021.
You asked the Plan to pay for the laboratory services. You say that the doctor regarded the gene panel test as medically necessary and valuable tool to treat the member. You say that the cost of the test should be covered at the in-network benefit level. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87841, 87496, 87500, 87529, 87532, 87640, 87635, 87798 and 87801) provided on May 25, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says these services were not billed with the appropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 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. Specifically, these services were billed with the laboratory place of service code while the record indicates that the member's face-to-face services was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for laboratory services (87841, 87496, 87500, 87529, 87532, 87640, 87635, 87798 and 87801) provided on May 25, 2021
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on September 6, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell down your basement stairs and the paramedics were called. You also say that they determined it was not best for your health to be transported by ambulance and called for an air ambulance. The Plan denied your request. The Plan says your request for ambulance services without transportation is not approved.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, 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. The record shows that the Plan contacted the ambulance billing department multiple times to request the run report for this date of service, but no records were provided. Based on this information, we decided that Medicare rules for coverage of the ambulance response and treatmulance response and treatment with no transport (A0998) provided on September 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing provided on August 26, 2021.

You asked the Plan to pay for the testing services. You say that the test informs clinicians about which
medications may require dose adjustments. The Plan denied your request. The Plan says the test has not been
shown to be useful.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file, and Medicare rules. The records provided do not show that the testing was ordered based
on signs, symptoms, or other clinical factors. PGx testing is not considered reasonable and necessary merely on
the basis of a patient having a particular diagnosis. Based on this information, we decided that Medicare rules
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay
for the GeneSight testing provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) provided on December 23, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 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 hospital outpatient clinic visit (G0463) provided on December 23, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), comprehensive oral evaluation (D0150), panoramic x-ray (D0330), simple extractions (D7140), and surgical extractions (D7210) provided from February 18, 2021, to September 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the problem focused limited oral evaluation, comprehensive oral evaluation, panoramic x-ray, and extractions. You say that you were referred by another provider. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that non-emergency services provided by an OON provider are not available with 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), comprehensive oral evaluation (D0150), panoramic x-ray (D0330), simple extractions (D7140), and surgical extractions (D7210) provided from February 18, 2021, to September 2, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit for debridement provided on March 22, 2021, and June 15, 2021.

You asked the Plan to waive the copayment for the outpatient clinic visits. You say that it was never explained this can be billed as outpatient surgery since the clinic is in a hospital. You say that the doctor is due a $35 copayment but not a copayment for outpatient surgery. The Plan denied your request. The Plan says the copayments applied 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 $400 copayment for outpatient surgery in an outpatient hospital facility.

You have been asked to pay $135.12, which is less than the standard $400 copayment for each outpatient clinic visit. The total amount you owe is $270.24 ($135.12/visit x 2 visits = $270.24). The outpatient clinic visits fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The outpatient clinic visits were for surgical 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 copayment for the outpatient clinic visit for debridement provided on March 22, 2021, and June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code 80307) provided to the enrollee on August 13, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network service. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 the drug testing (CPT code 80307) provided to the enrollee on August 13, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office services (CPT code 99202) provided on September 9, 2021.

You asked the Plan to waive the copayment for the office services. You say that the provider did not do anything, and they did not look at your because you did not get the Coronavirus (COVID) shot. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that you received office services on September 9, 2021. You were asked to pay a $45 copayment for the services. Your 2021 contract says that enrollees must pay a $45 copayment for each covered
visit or consultation in an outpatient location with a specialist. 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 office services (CPT code 99202) provided on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel
(R0075) set up portable x-ray equipment (Q0092) radiologic examination, chest (71045) provided on July 20,
2021, by an OON provider.

You asked the Plan to pay for the portable x-ray services. You say that your services are treated as an
emergency service in the nursing homes and home health settings. Your company is not allowed demographics
until the technologist is at the facility treating the patients.

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 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 transportation of portable x-ray equipment and
personnel (R0075) set up portable x-ray equipment (Q0092) radiologic examination, chest (71045) provided on
July 20, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on March 23, 2021.

You asked the Plan to pay for drug testing. 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 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 March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on September 7, 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 service 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 per visit with a primary care physician (PCP).
You have been asked to pay a $15 copayment for the office visit provided by your primary care physician medical group. An annual wellness visit was provided to you on this day. However, there were additional services provided that expanded beyond that of an annual 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 the office visit (99214) provided on September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the OON provider on
August 18, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered by the OON provider on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to
insufficient evidence of efficacy
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 device. Our reviewer says that the
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with
claudication. The record indicates that the enrollee has multi-level degenerative disease including moderate to
severe central spinal stenosis. The record documents that the enrollee is indicated for operative
intervention. The elements of the coverage criteria are not satisfied
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation - per site (D7953).

You asked the Plan to pre-approve bone replacement grafts. You say that you are in pain and need this service. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation - per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 11, 2021, by an
out-of-network (OON) provider.

You asked the Plan to reimburse you for hearing aids. You say that the in-network provider was too expensive
for hearing aids. You also say you went for a cheaper option. The Plan denied your request. The Plan says there
is no coverage for hearing aids, or related services received from an OON provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided by the Plan's hearing aid provider.

We looked at the file and the Plan's rules. The records show that the hearing aids were provided by an OON
provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been
met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August
11, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.

You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 8, 2022 forward and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors. He was 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and
has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The member has tolerated
inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services.
She could benefit from continued services at the current level of care. The member has made slow progress
with therapy, there is no indication that transfer to a skilled nursing facility is required. She can continue to
receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate.
There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF
for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility.