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

 We decided that the Plan does not have to pay for set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel (R0075) radiologic examination, abdomen (74018) provided on July 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for portable x-ray services. You say that your services are treated as an emergency service in the nursing home and home health setting. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel (R0075) radiologic examination, abdomen (74018) provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement foot orthotics (L3000).  You asked the Plan to pre-approve foot orthotics. You say that you require new foot orthotics done every year because the material in the orthotics breaks down after a year and does not wear as well. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.  The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment.  We looked at the file and Medicare rules. In this case, you are requesting a replacement for foot orthotics received by you in 2020. Therefore, the requested replacement is for items that have not outlasted their reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of foot orthotics have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement foot orthotics (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health services provided on September 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration because you have been seeing this provider for two years. The Plan denied your request. The Plan says this service was rendered out-of-network and without prior authorization from the Plan.  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 outpatient mental health services provided on September 24, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.

You asked the Plan to pre-approve 7 home health skilled nursing visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 7 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 14, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you do not remember seeing a specialist on the date of service. The Plan denied your request. The Plan says a specialist outpatient consultation was rendered, and the appropriate copayment was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered visit or consultation in an outpatient location with a specialist.     You have been asked to pay a $40 copayment for a specialist visit. The specialist visit falls within the Physician/Practitioner services, including doctor's office visits 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 a specialist visit provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology consultations (88334) provided on February 16, 2021.  You asked the Plan to pay for the pathology consultations. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 88334 and 88173.  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 88334 26 and 88334 26 XU is pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure).  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 pathology consultations.  Our reviewer says that CPT code  88334 26 does not meet criteria for billing or reimbursement consideration. CPT 88334 26 has a bundled relationship with CPT 88173.  A modifier is allowed to unbundle these services, however, an appropriate modifier was not added to 88334 26 when it was billed to the health plan, therefore no additional reimbursement is allowed. Our reviewer found CPT code 88334 26 XU does not meet criteria for billing or reimbursement consideration. The medical records do not include sufficient documentation to validate 88334 26 XU as a separate/distinct procedure to justify the use of a modifier to unbundle the service from 88173, therefore no additional reimbursement is allowed.  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 pathology consultations have not been met. Therefore, we decided that the Plan does not have to pay for the pathology consultations (88334) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on May 24, 2021.  You asked the Plan to waive the copayment for the laryngoscopy. You say that you feel that the copayment is excessive for this procedure. 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 $350 copayment per day for outpatient procedures and services.      You have been asked to pay a $350 copayment for the laryngoscopy. The laryngoscopy falls within the Outpatient Hospital 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 a laryngoscopy provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that BRCA genetic testing is covered when specific criteria are met.

We looked at the file and Medicare rules. The file shows that the testing is being requested for a personal history of malignant melanoma of the skin. This is not a diagnosis for which BRCA testing is covered. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services (64490, 64491, and 64492) provided on October 13, 2020.  You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this claim has not been coded correctly as required by Medicare coding regulations.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. In this case, no medical records were provided to corroborate the services as billed. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services (64490, 64491, and 64492) provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and amalgam - one surface, primary or permanent (D2140) provided January 20, 2021.  You asked the Plan to pay for the periodontal maintenance and filling. You say that this was a dental cleaning, and you don't understand what the charges are for. The Plan denied your request. The Plan says the claims have processed with 20% coinsurance correctly.  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. The Plan covers the periodontal maintenance and amalgam when the services are medically necessary and reasonable.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing that you were assessed 20% coinsurance for the periodontal maintenance and amalgam. 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 pay for the periodontal maintenance (D4910) and amalgam - one surface, primary or permanent (D2140) provided January 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services (S9501) provided on September 8, 2021, through September 10, 2021.  You asked the Plan to pay for the home infusion therapy services. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says CPT code S9501 has a status indicator of I.  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 CPT code S9501 is not supported in the record. Specifically, CPT code S9501 has a status indicator of I. This means that CPT code S9501 is not valid for Medicare purposes.  Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9501) provided on September 8, 2021, through September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper endoscopy (43239) provided on June 15, 2021.

You asked the Plan to waive the copayment for the upper endoscopy. You say that you cannot afford this cost. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 $350 copayment for outpatient procedures and services.

You have been asked to pay a $350 copayment for the upper endoscopy. An upper endoscopy falls within the outpatient procedures and 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 upper endoscopy (43239) provided on June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PrimaGen Allograft in the setting of posterior lumbar spine fusion surgery.
You asked the Plan to pre-approve this procedure. You say that this surgery is medically necessary. The Plan denied your request. The Plan says this surgery is not covered by Medicare.

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 this procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence in the peer-reviewed medical literature to support the use of bone graft allograft in the setting of transforaminal lumbar spine fusion surgery. Medicare does not pay for experimental services or devices.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this procedure have not been met.

Therefore, we decided that the Plan does not have to pre-approve PrimaGen Allograft in the setting of posterior lumbar spine fusion surgery.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on July 12, 2021.  You asked the Plan to pay for laboratory services. You say that you do not have a contractual agreement to include these services in the dialysis rate. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System (PPS) as Part B services and are not paid separately.  We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 83970, 84100) provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for laboratory tests provided on August 5, 2021.  You asked the Plan to waive the deductible for the laboratory tests. You say that the services should be covered as you have previously not had to pay for them under your previous health plan. The Plan denied your request. The Plan says the deductible applied correctly based on the services provided.  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 $500 deductible which applies to laboratory services.            The item or service you asked the Plan to waive the deductible for falls within the benefit category laboratory services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to laboratory services. This cost sharing is a contractual obligation that had not been met at the time the laboratory tests was received on August 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory tests provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021 and billed with CPT codes 82310, 82728, 83540, 83550, 83970 and 84100.  You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says laboratory tests that are related to ESRD treatment are considered integral to dialysis and may only be reported by the dialysis facility.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021 and billed with CPT codes 82310, 82728, 83540, 83550, 83970 and 84100.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel (R0070) radiologic examination, ribs, bilateral (71110) provided on July 27, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the portable x-ray services. You say that your services are treated as an emergency service in the nursing home and home health settings. Your company is not allowed access to demographics until the technologist is at the facility. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 set-up portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel (R0070) radiologic examination, ribs, bilateral (71110) provided on July 27, 2021 by an out-of-network (OON) provider.