Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral evaluation (D0160), provided on February 4, 2021.  You asked the Plan to pay for the oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says this service was obtained by a general dentist.  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 oral evaluation (D0160), provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical supplies provided to the enrollee from December 10, 2020 to December 16, 2020 and billed under codes J2260 and A4222.  You asked the Plan to pay for these items. You say that this claim should be paid. The Plan denied your request. The Plan says a valid physician order was not provided with the claim submission.  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. 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 medical supplies provided to the enrollee from December 10, 2020 to December 16, 2020 and billed under codes J2260 and A4222.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty.

You asked the Plan to pre-approve bronchial thermoplasty. You say that the first two procedures made you feel better, but there is one last procedure to do. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is considered experimental/investigational and unproven for any indication.

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 bronchial thermoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence shows that this procedure only provides short-term modest benefit for patients with added risks and does not have much quality evidence to show that benefits outweigh risks over the long-term. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bronchial thermoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wheelchair repairs to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says necessary services may be obtained 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and ankle feature.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for K3 foot does not meet the Medicare criteria as reasonable and 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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed your medical need, as the documentation does not reveal physician medical progress notes supporting the need for this level foot or that you meet your current functional needs with your K2 level foot.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and ankle feature.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenomic panel testing provided on April 2, 2021.
You asked the Plan to pay for pharmacogenomic panel testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because a panel constitutes a single procedural service so one procedure code must be billed for the panel.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomic multi-gene panels must be billed with procedure code 81479. We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of pharmacogenomic panel testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenomic panel testing provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network
(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
visit to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on January 14, 2020.

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 procedure code 99291 is not supported.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care time. 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 critical care services rendered on January 14, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an external electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage (93247) rendered on June 15, 2021.  You asked the Plan to waive the copayment for an external electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage. The Plan denied your request. The Plan says you were charged 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 $10 copayment per day for Medicare-covered outpatient diagnostic tests.    You have been asked to pay $10 copayment for an external electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage. An external electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an external electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage (93247) rendered on June 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on April 21,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for SNF care. You say that you provided medically necessary services in good faith.
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services
rendered by an out-of-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 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 skilled nursing facility (SNF) care, provided
on April 21, 2021 by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasound studies provided on December 17, 2020.

You asked the Plan to waive the copayments for ultrasound studies. You say that you only received one procedure and request the claims be reprocessed. 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 $110 copayment for each radiological diagnostic service. 

The record shows that you received two ultrasound studies on December 17, 2020. Therefore, you are responsible to pay a $110 copayment per each study. However, you are only being asked to pay the total amount of $181.76, which is less than the total copayment amount. 

You have been asked to pay $181.76 for ultrasound studies. Ultrasound studies 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 ultrasound studies provided on December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on
August 2, 2021.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you feel that the if the
physician had been there to read the first results you would not have had to have a second mammogram. 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 $35
copayment for each basic imaging service.
You have been asked to pay a $35 copayment for a diagnostic mammogram. A diagnostic mammogram falls
within the outpatient hospital services 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
diagnostic mammogram provided on August 2, 2021.
We note your complaint about having to have a second mammogram done. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you had on July 14, 2021.
You asked the Plan to waive the copayment for the TTE. You say that this should be covered in full as preventive care. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for radiological diagnostic services. You have been asked to pay a $125 copayment for the TTE. The TTE falls within the radiological diagnostic services benefit category. This copayment applies regardless of the length of time between appointments. 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 transthoracic echocardiography (TTE) you had on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on August 20, 2021.
You asked the Plan to pay for an eye refraction. You say that you have glaucoma, and you go to this office for a follow up on your condition and testing. The Plan denied your request. The Plan says Original Medicare doesn't cover eye refractions. The eye refraction was not part of a routine eye exam.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file, the Plan's rules and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on June 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the assisted living facility is responsible to obtain the prior authorization. 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on June 24, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43233), radiologic examination (74220), infectious agent detection by nucleic acid (87635), esophageal motility study (91010), esophageal function test (91037), and office consultation (99244) provided from July 27, 2021, to July 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the esophagogastroduodenoscopy, radiologic examination, infectious agent detection by nucleic acid, esophageal motility study, esophageal function test, and office consultation. You say that you do not agree with the denial for these services. The Plan denied your request. The Plan says the services received were not authorized or provided by your primary physician or contracted network providers. The Plan also says that unauthorized services, except emergency or urgent out-of-network services, are not payable by the Plan.  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 says that these services could have been provided in your area. 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 esophagogastroduodenoscopy (43233), radiologic examination (74220), infectious agent detection by nucleic acid (87635), esophageal motility study (91010), esophageal function test (91037), and office consultation (99244) provided from July 27, 2021, to July 30, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Procrit.  You asked the Plan to pre-approve Procrit. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, Retacrit for at least 2 months.  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 Procrit. Our reviewer says that Procrit does not meet the criteria for coverage. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, Retacrit. The reviewer found that there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. The reviewer found that the request for Procrit cannot be approved as the step therapy criteria has not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70470 provided on July 19, 2021.

You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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. In this case, we have confirmed that code 70470 for the computed tomography is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography coded 70470 provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on August 16, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the debridement services. You say that the service was 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 debridement services provided on August 16, 2021, by an out-of-network (OON) provider.