Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence wipes. 
 
You asked the Plan to pre-approve incontinence wipes. You say that the items are necessary. The Plan denied 
your request. The Plan says the requested items are not primarily medical in nature. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve incontinence wipes.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided on April 26, 2021 by a 
non-network provider. 
 
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 services were rendered by a non-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 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 chemotherapy services provided on April 26, 
2021 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging, brain, including brain stem (70553) provided June 18, 2021.

You asked the Plan to pay for the diagnostic services. You say that the procedure was rendered in appropriate place of service. Please review and reconsider the claim for payment. The Plan denied your request. The Plan says the claim has missing/incomplete/invalid/inappropriate place of service.

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 70553 is magnetic resonance (eg, proton) imaging, brain (including brain stem).

We find that CPT code 70553 is not supported in the medical record. Specifically, the claim was billed with an inappropriate place of service of 22 for outpatient. The claims history shows that the enrollee was inpatient during dates of service June 13, 2021 to June 24, 2021. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging, brain, including brain stem (70553) provided June 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient hospital services provided from April 24, 2021, to May 11, 2021.

You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you were told that your copayment would only be $650, but you are being billed another $375 copayment. 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 $325 copayment per day for days 1-5 for inpatient hospital care (including inpatient rehabilitation). 

Records show that you were in an inpatient hospital facility from April 24, 2021, to April 27, 2021. You were then discharged and transferred to an inpatient rehabilitation facility from April 27, 2021, to May 11, 2021. Because inpatient rehabilitation is also considered an inpatient hospital stay, both of these stays contribute to your inpatient cost sharing. You were in an inpatient status for a total of 15 days. You were charged a $325 copayment per day for each of the first 5 days, for a total of $1625.00. 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 reduce the copayment for inpatient hospital services provided from April 24, 2021, to May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider from June 1, 2021, through June 28, 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 out-of-network (OON) provider from
June 1, 2021, through June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on January 20, 2021 to January 22, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on January 20, 2021 to January 22, 2021.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be given in an alternate level of care, such as skilled nursing facility or at home with home health care services.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cancer genetic panel (81317, 81405, 81404, 
81406) provided on February 22, 2021. 
 
You asked the Plan to pay for a hereditary cancer genetic panel. You say that this is supported in the records. 
The Plan denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a 
patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so 1 code must be submitted for the panel. 
 
We find that CPT codes 81317, 81405, 81404, and 81406 are not supported in the medical record. Specifically, 
these codes were used to report a panel, which should be billed with one code.

Based on this information, we decided that Medicare rules for coverage of a hereditary cancer genetic panel 
have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cancer genetic 
panel (81317, 81405, 81404, 81406) provided on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81295, 81298, 81407, 81408) provided on April 14, 2021.

You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.

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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81295, 81298, 81407, 81408) provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames, progressive lenses, anti-reflective coating and
miscellaneous vision item provided on March 8, 2021.

You asked the Plan to pay for the frames, progressive lenses, anti-reflective coating and miscellaneous vision
item. You say that you thought you were okay since you did not purchase glasses in 2020 and the 30-day
difference should be allowed. The Plan denied your request. The Plan says you exhausted the benefit on April
04, 2019.

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. The Plan covers these services up to $240 every 24 months.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the frames, progressive lenses, anti-reflective coating and miscellaneous vision item have not been
met. Specifically, the services were provided before 24 months. Therefore, we decided that the Plan does not
have to pay for the frames, progressive lenses, anti-reflective coating and miscellaneous vision item provided
on March 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99053) provided on December 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is
mutually exclusive to another billed code.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan argues that code 99053 is mutually exclusive to code 99291, which
was billed on the same claim. However, an NCCI code pair edit search does not show that a column I/column
II relationship exists between these two codes. The Plan has not provided documentation showing that these
two codes cannot be billed on the same claim. Without supporting documentation, the Plan's denial cannot be
substantiated. Therefore, we decided that the Plan has to pay for the services (99053) provided on December
30, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan must show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance services represented by code 76937 provided on April 27, 2021.
You asked the Plan to pay for code 76937. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76937 has a bundled relationship with code 93971 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 ultrasound guidance services represented by code 76937 provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 2, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the epidurography rendered on February 11, 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 procedure code 72275 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 72275 (epidurography) and 64483 (transforaminal epidural injection). Code 72275 is a column II code with a modifier indicator of 1 when billed with column I code 64483. Code 72275 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the epidurography rendered on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the lumbar spinal canal and contents (72148) provided at an outpatient hospital facility on July 2, 2021.

You asked the Plan to waive the copayment for an MRI scan of the lumbar spine. You say that the providing facility is not a hospital and your copayment should be $180. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for advanced imaging services at an outpatient hospital. In this case, the record shows the advanced imaging services at issue were provided at an outpatient hospital facility. 

You have been asked to pay $212.18 for an MRI scan of the lumbar spine. An MRI scan of the lumbar spine falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 MRI scan of the lumbar spinal canal and contents (72148) provided at an outpatient hospital facility on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture and infrared therapy services provided on March 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. The rules also say that infrared therapy services are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records show that the acupuncture services were provided for shoulder pain. Additionally, per Medicare rules, infrared therapy services are also non-covered. Therefore, we decided that the Plan does not have to pay for the acupuncture and infrared therapy services provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on July 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. 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 service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on July 9, 2021, 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 additional cost of the trifocal intraocular lenses provided
on July 2, 2019, and July 30, 2019.

You asked the Plan to pay for the additional cost of the trifocal intraocular lenses. You say that you needed two
specialty lenses for astigmatism. You say that you are appealing the additional cost related to the premium
lenses. The Plan denied your request. The Plan says trifocal intraocular lenses are not covered.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL. This includes the additional facility or physician's charge that exceeds the facility or
physician's charge for insertion of a conventional intraocular lens (IOL).

While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting
feature of an IOL. Therefore, we decided that the Plan does not have to pay for the additional cost of
the trifocal intraocular lenses provided on July 2, 2019, and July 30, 2019.