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

We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 9, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because the bill should have been processed by Medicaid. 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 $100 copayment for ultrasounds. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring system (A9276, A2977, A9278).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet the Medicare criteria.
The Plan must follow Medicare rules. The rules say that Healthcare Common Procedure Coding System (HCPCS A9276, A9277, and A9278 are not covered codes. The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitoring system (A9276, A2977, A9278).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the enrollee's condition is not controlled with the standard glucose monitors. It is felt that the CGM is medically necessary to control her diabetes. The Plan denied your request. The Plan says the criteria for CGM are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily administrations. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on July 10, 2021, billed with code 70450.
You asked the Plan to pay for the billed code 70450. You say that this should be paid as multiple exams were done on the same date. The Plan denied your request. The Plan says the Column 2 code was not billed with an appropriate modifier.
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 the billed code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on July 10, 2021, billed with code 70450.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on May 17, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says that the documentation does not show 22 or more classes were tested.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the medical record. Specifically, the submitted records show that more than 22 drug classes were tested. The classes tested include Alcohol biomarkers; Amphetamines; Antidepressants, serotonergic class; Antidepressants, tricyclic and other cyclicals; Antidepressants, not otherwise specified; Antipsychotics, not otherwise specified; Barbituates; Benzodizepines; Buprenorphine; Cannabinoids, natural; Cannabinoids, synthetic; Cocaine; Fentanyls; Gabapentin, non-blood; Heroin metabolite; Ketamine and Norketamine; Methadone; Methylenedioxyamphetamines; Methylphenidate; Opiates; Opioids and opiate analogs; Oxycodone; Phencyclidine; Pregabalin; Propoxyphene; Sedative Hypnotics (non-benzodiazepines); Skeletal muscle relaxants; Stimulants, synthetic; Tapentadol; and Tramadol. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on May 17, 2021.
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 has to 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Alpha Lipoic acid and L-Carnitine injected during a Sanexas device treatment on February 3, 2021, billed with codes J7999 and J7999-59.
You asked the Plan to pay for the nutria-pharmaceuticals as billed. You say that this should be paid. The Plan denied your request. The Plan says these services are not medically necessary based on Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that compounded drugs are to be billed using code J7999 with the ingredients listed in the appropriate section of the claim. In this case, the record shows that multiple agents are included in the injections provided. It is not appropriate for bill two of these on a separate claim. The rules require all agents in the compounded drug to be billed and reported under J7999 together. Therefore, we decided that the Plan does not have to pay for the Alpha Lipoic acid and L-Carnitine injected during a Sanexas device treatment on February 3, 2021, billed with codes J7999 and J7999-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient services from November 12, 2021, forward.
You asked the Plan to pre-approve inpatient services from November 12, 2021, forward. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient services from November 12, 2021, forward. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was medically stable and cleared for discharge and has been waiting to be placed in another facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services from November 12, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient services from November 12, 2021, forward
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on July 14, 2021.
You asked the Plan to pay for the dental service. You say that a full mouth debridement is similar to a cleaning. You also say that you feel this service should be covered. The Plan denied your request. The Plan says full mouth debridement is specifically listed as a dental service that is not covered.
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 full mouth debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on July 14, 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient 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 you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 30, 2021.

You asked the Plan to pay for the dental service. You say that the previous dentist you saw is 1 hour away from your house. You say that you can no longer go there. You say that this provider is much closer to you. You also say that you would like an exception to be made. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

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 comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on November 20, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 30, 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 April 2, 2021.
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 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 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 out of network physician services provided to the enrollee on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954) provided by a participating provider.

You asked the Plan to pre-approve a prefabricated post and core. You say that you do not have a lot of money. You say that you are missing a lot of teeth and you need this procedure done. The Plan denied your request. The Plan says the dental services that are being requested are not covered services.

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 pre-approve a prefabricated post and core (D2954) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87481 provided on May 25, 2021.
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique.
We find that CPT code 87481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87481 provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile supplies (0272), surgical supplies (0270), outpatient clinic visit (G0463) and debridement of subcutaneous tissue (11042) provided on May 6, 2021, to May 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary and provided in good faith. The Plan denied your request. The Plan says prior authorization was not obtained prior to rendering the services. The Plan says that the services were not urgent or emergent.
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. Therefore, we decided that the Plan does not have to pay for the sterile supplies (0272), surgical supplies (0270), outpatient clinic visit (G0463) and debridement of subcutaneous tissue (11042) provided on May 6, 2021, to May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder assay provided on May 5, 2021.
You asked the Plan to pay for the CxBladder testing. You say that this testing is clinically validated in peer-reviewed journals. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the CxBladder assay has been reviewed, and noncoverage for this test has been reaffirmed. Therefore, we decided that the Plan does not have to pay for the CxBladder assay provided on May 5, 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 May 27, 2021, to June 25, 2021.

You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services.

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. 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 have not been met. Specifically, the file shows that the enrollee did not receive daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 27, 2021, to June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening examination coded as 88162 provided on November 30, 2020.
You asked the Plan to pay for the screening examination. You say that you would like this claim reprocessed and approved for payment based on the medical records provided. 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 the screening examination is a column II code to column I code 88305. 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 screening examination coded as 88162 provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on April 8, 2021.

You asked the Plan to pay for the services provided. You say that services have been paid for in the past based on out-of-network benefits. The Plan denied your request. The Plan says the provider opted out of the product.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the dermatology services provided on April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diagnostic mammograms provided on August 17, 2021.
You asked the Plan to waive the coinsurance for diagnostic mammograms. You say that the mammograms should be considered preventative and processed as screenings. 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 20% coinsurance for diagnostic procedures and tests. The medical records show that you received diagnostic mammograms on August 17, 2021. The total allowed amount is $324.56 and 20% of that is $64.91.
You have been asked to pay the total coinsurance amount of $64.91 for diagnostic mammograms. Diagnostic mammograms fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for diagnostic mammograms provided on August 17, 2021.