Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital care provided to the enrollee on July 20, 2021.  You asked the Plan to pay for the services. You say that although the enrollee was treated as inpatient twice, the enrollee was seen by different specialists. The Plan denied your request. The Plan says the services were processed correctly.  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 99232 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit."  We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found when reporting and evaluation and management code with a cardiovascular stress test, an appropriate modifier should be appended that indicates a separately identifiable evaluation/management service was performed on the same day as the stress test.   We looked at this coder'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 pay for hospital care provided to the enrollee on July 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis (74178) provided on May 11, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you thought this service would be covered in full because you had a referral. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. The CT scan is covered, but there is a $250 copayment required for diagnostic radiology services other than ultrasounds and x-rays.  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 $250 copayment for other Medicare-covered diagnostic radiology services.   You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the other Medicare-covered diagnostic radiology 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 the computed tomography (CT) scan of the abdomen and pelvis (74178) provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa (J7323).  

You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.    

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 Euflexxa. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective for this enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ferumoxytol (Feraheme).

You asked the Plan to pre-approve Feraheme. You say that you are feeling faint and need this iron shot. The Plan denied your request. The Plan says you have not tried and failed Ferrlecit, Infed, or Venofer.

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 Feraheme. Our physician reviewer found that in this case, the record indicates you have iron deficiency anemia from chronic blood loss. The requested medication is a new start. The Plan requires a trial of Ferrlecit, Infed, or Venofer before they will approve the requested drug. The provided records do not indicate that you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve ferumoxytol (Feraheme).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report provided on August 19, 2021 by a non-participating 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-participating 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 referring provider 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 electrocardiogram (EKG) interpretation and report provided on August 19, 2021 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on August 7, 2021.  You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier 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 76705 is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on August 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the filling (D2392) provided on April 29, 2021.  You asked the Plan to pay for the filling provided on April 29, 2021. You say that this service was pre-authorized. You say that this pre-authorization should have been processed the correct way. You also say that you should not be responsible for these bills. The Plan denied your request. The Plan says you pay a 20% coinsurance for fillings received in network. The Plan also says that payment is applied after the $50 deductible has been met.  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 and fillings are listed as covered, there is a deductible that applies before payment is made. The record shows that the deductible had not been met prior to the date of service. The record shows that the Plan applied the $50 deductible to the billed amount of $98. $98 - $50 = $48. You pay 20% for fillings received in network. $48 x 20% = $9.60. $50 (deductible) + $9.60 (coinsurance) = $59.60. Therefore, we decided that the Plan does not have to pay an additional amount for the filling (D2392) provided on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical trays provided on March 29, 2021.

You asked the Plan to pay for surgical trays. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this item is always bundled for payment and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that code A4550 is always bundled for payment and if it is covered the payment for it is subsumed by the payment for the item/service to which it is incident. 

We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for surgical trays provided on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on June 18, 2021.
You asked the Plan to pay for the SelectMDx testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says there was no documented result of prior prostate biopsy.
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for services that are not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SelectMDx testing have not been met. Specifically, per the Diagnostics Exchange, SelectMDx is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an MRI scan of the hand (73220).  You asked the Plan to pre-approve an MRI of the hand. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been met.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   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 an MRI of the hand. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had plain films and an MRI over a year ago. The record indicates that the enrollee has clinically responded to treatment. No recent imaging has been performed. The records provided do not indicate the medical necessity or reasonableness of the requested service at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the hand have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the hand (73220).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 26, 2021, to April 29, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you went to the hospital due to complications from a routine biopsy. You say that you should not be responsible for these charges. 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 $395 per day for days 1-5 and $0 per day after day 5 for each inpatient stay. 

The record shows that you were in the hospital from April 26, 2021, to April 29, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $395 per day for the first three days for the inpatient hospital services. The total for your stay is $1185. Inpatient hospital services fall within the Inpatient Hospital Care 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 inpatient hospital services provided from April 26, 2021, to April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 15, 2021, to May 10, 2021.

You asked the Plan to pay for the SNF care provided from April 15, 2021, to May 10, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled care on the dates of service in this case.

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 pay for the SNF care provided from April 11, 2021, to April 14, 2021. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

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 SNF care provided from April 15, 2021, to May 10, 2021, have not been met. Specifically, the file shows that the enrollee did not require skilled care on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 15, 2021, to May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on February 12, 2021.  You asked the Plan to pay for drug 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 the documentation submitted does not support the Place of Service (POS) code billed on this claim.  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 documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. 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 provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81238, 81410, 81411) provided May 13, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the testing performed is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular genetic risk assessment panels. 

We looked at the file and Medicare rules. The test performed is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81238, 81410, 81411) provided May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 18, 2021.  

You asked the Plan to pay for the services. You say that this should be paid The Plan denied your request. The Plan says the denied codes remain 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.  

We find that the denied CPT codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11) 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 pay for laboratory services provided to the enrollee on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on July 20, 2021.  

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions are not covered by Medicare or by the Plan.  

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 and the Medicare rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (00300) provided on September 15, 2020.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the records provided. The Plan denied your request. The Plan says they are not the primary insurance plan the enrollee has in this case.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed the provider to bill the enrollee's primary insurance as referenced in the decision letter. As the secondary insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00300) provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310).

You asked the Plan to pre-approve endodontic therapy. You say that you disagree with the denial and are requesting reconsideration. The Plan denied your request. The Plan says the requested service is not listed as a covered service with the enrollee's 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 endodontic therapy is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3310).