Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services and X-rays and does not have to waive the coinsurance for Medicare Part B drugs provided on July 7, 2021.
You asked the Plan to waive the copayments for specialist services and X-rays and to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges and feel that seniors are being taken advantage of. 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 specialist visits. Your contract with the Plan also clearly says that you must pay a $75 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received specialist services on July 7, 2021. Therefore, you are responsible to pay the $35 copayment. You received X-rays on July 7, 2021. Therefore, you are responsible to pay the allowed amount of $61.18, which is less than the $75 copayment. You received Medicare Part B drugs on July 7, 2021. The total allowed amount is $522.72 and 20% of that is $104.54. The total amount you owe is: $200.72. You have been asked to pay the total amount of $200.72 for specialist services, X-rays and Medicare Part B drugs. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 specialist services and X-rays and does not have to waive the coinsurance for Medicare Part B drugs provided on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services coded as 93976 and provided on August 2, 2021.  You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed based on the medical documentation submitted. The Plan denied your request. The Plan says an appropriate modifier was not billed with these services as required by Medicare rules.  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 93976 is a column II code to column I code 76856. 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 ultrasound services coded as 93976 and provided on August 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on March 31, 2021.
You asked the Plan to pay for the hospital discharge day management. You say that the patient was seen through the emergency room and evaluated by the physician for medically necessary services. You attached documentation that support the service provided and the claim should be processed for payment. 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 the hospital discharge day management provided on March 31, 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 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the annual wellness visit (CPT code G0439) provided on August 20, 2021.
You asked the Plan to pre-approve the annual wellness visit. You say that this service was referred to by your doctor as a "Meet and Greet". The Plan denied your request. The Plan says this service is limited to once a benefit year and the benefit limit has been reached.
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. Based on this information, we decided that Medicare rules for
coverage of the annual wellness visit have not been met. The health plan contract says if you've had Part B for longer than twelve (12) months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. Therefore, we decided that the Plan does not have to pre-approve the annual wellness visit (CPT code G0439) provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neuromonitoring services (95861, 95938, 95865, 95939) on May 10, 2021.
You asked the Plan to pay for intraoperative neuromonitoring services. You say that these services were approved and billed correctly. The Plan denied your request. The Plan says these services should be billed through the facility.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another place of service (POS) code already exists, providers should use the POS code for that entity. We looked at the file and Medicare rules. The records show that the service at issue provided by a mobile unit were provided in service of another entity. Based on this information, we decided that Medicare rules for coverage of intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan
does not have to pay for intraoperative neuromonitoring services (95861, 95938, 95865, 95939) on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and rooting (D4341), and resin based composite (D2394), provided on August 27, 2021, and August 28, 2021.
You asked the Plan to pay for the periodontal scaling and rooting and resin based composite. You say that the services should be covered. The Plan denied your request. The Plan says your payment responsibility is correct.
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 periodontal scaling and rooting (D4341), and resin based composite (D2394), provided on August 27, 2021, and August 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. 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 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 based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periacipal radiographic image (x-ray) (D0220), limited evaluation (D0140), re-cement or re-bond crown (D2920), provided on April 5, 2021.
You asked the Plan to pay for the periacipal x-ray, limited evaluation and crown. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periacipal radiographic image (x-ray) (D0220), limited evaluation (D0140), re-cement or re-bond crown (D2920), provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Bio Choice hereditary cardio screen (CPT code(s): 81401, 81403, 81404, 81305, 81406, 81407, and 81408) provided to the enrollee on April 23, 2021.  You asked the Plan to pay for the laboratory services. You say that the services were necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of molecular cardiovascular profile for risk stratification in asymptomatic individuals have not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the clinical value and effectiveness of molecular cardiovascular profile testing for risk stratification in asymptomatic individuals has not been demonstrated in the peer reviewed literature. The review has determined that the items/services at issue in this case are not medically reasonable or 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 the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the Bio Choice hereditary cardio screen (CPT code(s): 81401, 81403, 81404, 81305, 81406, 81407, and 81408) provided to the enrollee on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for eye surgery performed on August 9, 2021.  You asked the Plan to waive the copayment for the eye surgery. You say that you would like the copayment refunded as you did not intend to have a second procedure done. The Plan denied your request. The Plan says you have been 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 a $225 copayment for each outpatient surgery at an ambulatory surgical center.   You have been asked to pay a $225 copayment for the eye surgery. Eye surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 eye surgery performed on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiovascular genetic risk assessment (CPT code(s): 81226, 81227, 81230, 81231, 81240, 81241, 81286, 81291, 81292, 81335, 81350, 81355, 81380, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided to the enrollee on February 17, 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 service is not covered as billed.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Medicare denies coverage for all cardiovascular genetic risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic risk assessment (CPT code(s): 81226, 81227, 81230, 81231, 81240, 81241, 81286, 81291, 81292, 81335, 81350, 81355, 81380, 81403, 81404, 81405, 81406, 81407, 81408, 81479) provided to the enrollee on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for unlisted anesthesia procedure for an IPACK block (CPT code 64999-59) provided to the enrollee on July 16, 2021.  You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied your request. The Plan says the service is considered experimental and investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found patients who have an IPACK block will have the posterior part of their knee numbed. Because it does not cover the entire knee, the IPACK block is often used in combination with an anterior knee block and a spinal or epidural for surgical anesthesia. This procedure has no Hayes rating and therefore, there is not enough proof to support the safety and success of their use. There is no specific clinical indication for the proposed procedure. The review has determined that the items/services at issue in this case are not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not have to pay for unlisted anesthesia procedure for an IPACK block (CPT code 64999-59) provided to the enrollee on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81003, 81025, 87070) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on August 27, 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 (81003, 81025, 87070) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the injection procedure you received in a specialist's office, the epidurogram, the betamethasone acetate injection, and the propofol injection you received on July 13, 2021.  You asked the Plan to waive the cost sharing for the injection procedure, the epidurogram, and the drugs. You say that these services should all be covered by your plan with no additional monies due. The Plan denied your request. The Plan says you were charged these cost sharing amounts correctly.  The Plan says that because the allowed amount for the epidurogram ($96.02) is less than your cost sharing obligation for that service, you are responsible for the full allowed amount for that service.  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 $20 copayment for services with a specialist.   You have been asked to pay a $20 copayment for the injection procedure you had in a specialist's office, a $125 copayment for the epidurogram, and 20% coinsurance for the two drugs you received.  This means that you have been asked to pay the correct amounts 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 cost sharing for the injection procedure you received in a specialist's office, the epidurogram, the betamethasone acetate injection, and the propofol injection you received on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, 87641, and 87798) provided to the enrollee on August 4, 2020.  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.  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. CPT code(s): 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, 87641 and 87798, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in POS 32 Nursing Facility. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87500, 87502, 87532, 87541, 87581, 87634, 87640, 87641, and 87798) provided to the enrollee on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213), chiropractic manipulative treatment (98941), manual therapy techniques (97140), and the therapeutic exercises (97530) rendered by the out-of-network (OON) provider from January 5, 2021, through March 30, 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 office visit (99213), chiropractic manipulative treatment (98941), manual therapy techniques (97140), and the therapeutic exercises (97530) rendered by the out-of-network (OON) provider from January 5, 2021, through March 30, 2021.