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

We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination (88307) morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody (88360) provided February 25, 2021.

You asked the Plan to pay for the laboratory services. You say that the enrollee was enrolled in hospice until 2/19/2021 and this date of service in 6 days after that. You ask that this claim be reopened and reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on February 19, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination (88307) morphometric analysis, tumor immunohistochemistry, quantitative or semiquantitative, each antibody (88360) provided February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 8, 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 were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on January 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on December 11, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first.
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 testing services provided to the enrollee on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the secondary closure of surgical wound or dehiscence,
extensive or complicated (13160) provided May 5, 2021.
You asked the Plan to pay for the surgical procedure. You say that the surgical assistant was chosen by the
surgeon completely at the surgeon's discretion and the surgical assistant had no choice to not be on the case and
ethically could not deny the services to the enrollee. The Plan denied your request. The Plan says this is not
medically necessary because the procedure requested does not require an assistant.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 13160. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Therefore, we decided that the Plan does not have to pay for the secondary
closure of surgical wound or dehiscence, extensive or complicated (13160) provided May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular testing (81291, 81404, 81405, 81406, 81407, 81408, 81439, 81479) provided on June 30, 2020.
You asked the Plan to pay for hereditary cardiovascular testing. You say that this was billed correctly. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular testing (81291, 81404, 81405, 81406, 81407, 81408, 81439, 81479) provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for travel and lodging provided from May 24, 2021, to May 26, 2021.
You asked the Plan to pay for the services provided. You say that you had testing for an aortic valve replacement. The Plan denied your request. The Plan says travel is reimbursed only when your transplant is done.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
We looked at the file and the rules. The records do not show that transplant services were provided for the dates of service at issue. Based on this information, we decided that the rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for travel and lodging provided from May 24, 2021, to May 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on December 14, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you thought that if services were related to the coronavirus the copayment would be waived. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency care. The medical records show that the enrollee received emergency care due to hypotension on December 14, 2020. There is no indication that services were rendered due to the coronavirus. Therefore, the enrollee is responsible to pay the $120 copayment. The enrollee has been asked to pay a $120 copayment for emergency care. Emergency care falls within the
emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and tests provided on July 15, 2020 by an out-of-network provider.
You asked the Plan to pay for the office visit (99214) and tests (80307, 82962). You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 office visit and tests provided on July 15, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary.
The Plan denied your request. The Plan says Medicare does not cover this item.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 24, 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 the services are not covered.
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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Enteral formula metabolic drink (B4154).
You asked the Plan to pre-approve the Enteral formula metabolic drink. You say that you need this item to help
support your diet. The Plan denied your request. The Plan says nutritional supplements or formulas that are
administered orally are not covered under any condition.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan
does not have to pre-approve the Enteral formula metabolic drink (B4154).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or CNA provided from January 27, 2021, to
January 31, 2021.
You asked the Plan to pay for the HHA or CNA. The Plan denied your request. The Plan says the treating
provider does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items
or services, a provider or supplier must be enrolled in the Medicare program.
We looked at the file and Medicare rules. The services were rendered by a non-certified Medicare provider.
Based on this information, we decided that Medicare rules for coverage of the HHA or CNA have not been
met. Therefore, we decided that the Plan does not have to pay for the HHA or CNA provided from January 27,
2021, to January 31, 2021.
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 January 15, 2021.
You asked the Plan to waive the copayment for the TTE. You say that it is not clear why you are being asked to pay $125 when that is not equal to 20% of the cost for this service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this is a flat copayment, not coinsurance (which is a percentage of the allowed 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 $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 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 January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says no necessity for an out-of-network provider, such as an urgent or emergency situation has been documented.
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 laboratory services provided on February 25, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ankle orthosis (L4350), provided on May 17, 2021.
You asked the Plan to waive the coinsurance for the ankle orthosis. You say that the item should be covered. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the ankle orthosis. This item falls within the durable medical equipment (DME) and related 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 coinsurance for the ankle orthosis (L4350), provided on May 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance service (A0427) and mileage
(A0425) provided on April 29, 2021.
You asked the Plan to waive the deductible for the ambulance services. You say that the service should be
covered. The Plan denied your request. The Plan says you have not met your deductible for the Plan year.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Ambulance
Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible before the ambulance copayment take effect. This cost sharing is a contractual obligation that had
not been met at the time the ambulance services was received on April 29, 2021. Therefore, we decided that the
Plan does not have to waive the deductible for the ambulance service (A0427) and mileage (A0425) provided
on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on November 6, 2020.
You asked the Plan to pay for the services provided. You say that the testing helps make informed decisions regarding a treatment plan. The Plan denied your request. The Plan says the enrollee did not meet the requirement for approval.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The records show that a fine needle aspiration was done which indicated a positive malignancy consistent with papillary carcinoma. The testing at issue is covered when there is an indeterminate pathology on fine needle aspiration. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically
necessary and appropriate for this enrollee. The Plan denied your request. The Plan says the criteria for
admission to an LTACH have not been met. The enrollee's needs are being met in the current acute setting. The
LTACH would provide no additional services. With additional time in the current setting, clinical stability can
be ensured such that the appropriate lower level of care can be determined.
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 indicating medical necessity for LTACH
services. 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 they are 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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast magnetic resonance imaging (MRI) interpretation provided on March 3, 2021.

You asked the Plan to pay for the breast MRI (77049) interpretation. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this screening test is not a Medicare benefit.

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 breast MRI (77049) interpretation, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the breast magnetic resonance imaging (MRI) interpretation provided on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided on April 5, 2021.
You asked the Plan to waive the copay for the CT scan. You say that you should not be charged for the service. The Plan denied your request. The Plan says the coinsurance was applied per your plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance up to $75 for Medicare-covered diagnostic radiology services.
You have been asked to pay $50.33, which is a 20% coinsurance for the CT scan. The CT scan falls within the outpatient diagnostic tests 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 copay for the computed tomography (CT) scan provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (36415, 85610) provided to the enrollee on
May 27, 2021, by an OON provider.

You asked the Plan to pay for these services. You say that that the enrollee wishes to continue seeking services
for her condition under this physician at this location. The Plan denied your request. The Plan says that these
services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the lab services (36415, 85610) provided to the
enrollee on May 27, 2021, by an OON provider.