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

 We decided that the Plan does not have to pay for the tissue exam and special stains (88312 and 88305) provided on March 8, 2021.  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 these codes are not payable on the billed claim.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT codes 88312 and 88305 are not supported in the record. Specifically, the record indicates that this member is a hospital outpatient. The technical component of these codes would paid to the facility and the facility would be responsible for payment to any vendor. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the tissue exam and special stains (88312 and 88305) provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (76942, 77001) provided on January 25, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.  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 76942 is a column II code to column I code 76937, and code 77001 is a column II code to column I code 76942. 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 services (76942, 77001) provided on January 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 17 home health aide visits.  You asked the Plan to pre-approve 17 home health aide 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 HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 17 home health aide 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 your condition, or to establish/perform a maintenance program to maintain your 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 your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The services do not meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2. The home health aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 17 home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 17 home health aide visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on June 17, 2021.  You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you were not advised that the treating provider was not in-network with the Plan. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.  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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pembrolizumab and cetuximab for the enrollee.  You asked the Plan to pre-approve pembrolizumab and cetuximab. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 pembrolizumab and cetuximab. Our reviewer says that pembrolizumab and cetuximab are not medically reasonable and necessary for the enrollee. The requested use of pembrolizumab and cetuximab is not FDA-approved for the enrollee's diagnosis in combination. The use of pembrolizumab and cetuximab is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pembrolizumab and cetuximab have not been met. Therefore, we decided that the Plan does not have to pre-approve pembrolizumab and cetuximab for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit (99213) rendered on November 30,
2020.

You asked the Plan to waive the copayment for an office visit. You say that you were advised by the Plan that
you had met your out-of-pocket maximum prior to these services. The Plan denied your request. The Plan says
that you were charged the correct cost sharing amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. the Plan has not provided any evidence of how they calculated your out-of-pocket
maximum for 2020. In fact, the only documents they provided in the case file they submitted related to
your costs are the Explanations of Benefits from this period that explicitly state that you had met your out-of-pocket
maximum. They provided no evidence to the contrary in the case file. The burden is on the Plan to
show why their assessment of coinsurance was correct, and they have failed to do so in this case. Therefore, we
decided that the Plan has to waive the copayment for an office visit (99213) rendered on November 30, 2020.

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 medical nutrition therapy (97804) provided on November 16, 2020.  You asked the Plan to pay for medical nutrition therapy. You say that this was required following surgery. The Plan denied your request. The Plan says this was not billed with a covered diagnosis.  The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy is for certain beneficiaries who have diabetes or a renal disease.  We looked at the file and Medicare rules. The billed diagnoses do not show that you have diabetes or a renal disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97804) provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740) provided on February 8, 2021.  You asked the Plan to pay for the dental services. You say that you were assured by a plan representative that you had coverage before incurring fees from this provider. You say that the services were approved for payment. You also say that you should not have to remit payment. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services provided by a dentist that has opted out of Medicare.  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, dental services provided by a dentist that has opted out of Medicare are not among those covered under this benefit. The record shows that you signed a Notice of Medicare Opt-Out Agreement prior to receiving the services, acknowledging that you would be financially responsible for the charges as the dentist has opted out of Medicare. Additionally, the record shows that the Plan confirmed there is no record of you contacting the Plan regarding this provider until after the date of service. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) and crown (D2740) provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.

You asked the Plan to pre-approve non-sterile gloves. You say that you need the gloves to be hygienic while caring for your husband. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that non-sterile gloves are not covered because they are hygienic items that are non-reusable. 

While non-sterile gloves may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99336) provided on July 2, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 service 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 physician services (99336) provided on July 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a colonoscopy with biopsy (45380) provided on June 18, 2021.  You asked the Plan to waive the coinsurance for a colonoscopy with biopsy. You say that you were told you would not owe anything, and you did not know polyps were found since you were under anesthesia. The Plan denied your request. The Plan says the cost share 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 outpatient surgery.   You have been asked to pay a 20% coinsurance for a colonoscopy with biopsy. The services at issue fall within the outpatient surgery 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 a colonoscopy with biopsy (45380) provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81493) provided June 29, 2020.

You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says this test is not covered under Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that the Corus CAD test is non-covered. 

We looked at the file and Medicare rules. The testing at issue 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 (81493) provided June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 30, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services provided by an out-of-network provider on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for services you received on April 17, 2021, with an out-of-network provider.

You asked the Plan to waive the coinsurance for the out-of-network nurse practitioner services. You say that you went to the walk-in clinic because it was near your home. You said that you thought your insurance would pay for it. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network physician and practitioner services. 

You have been asked to pay 50% coinsurance for the out-of-network services. 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 services you received on April 17, 2021, with an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on March 11, 2021.  You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your request. The Plan says for reviewing additional services provided, the Plan has requested a run report for each transport provided on this date of service. The provider has failed to submit the requested documents.  The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for services you received on April 6, 2021, with an out-of-network nurse practitioner.  You asked the Plan to waive the coinsurance for the out-of-network services. You say that you went to the walk-in clinic because it was near your home. You said that you thought your insurance would pay for it. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network physician and practitioner services.    You have been asked to pay 50% coinsurance for the out-of-network services. 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 services you received on April 6, 2021, with an out-of-network nurse practitioner.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on July 6, 2020.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

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 testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. 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 (G0483) provided on July 6, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) provided on May 11, 2021.  You asked the Plan to pay for services provided between 10:00 PM and 8:00 AM. You say that you do not believe the amount paid on this claim is fair. The Plan denied your request. The Plan says this code is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Code 99053 has a status indicator of B, meaning payment for this service is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) provided on May 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on May 30, 2020.   You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.  The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on May 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab testing (81408, 81286, 81479, 81404) provided March 25, 2021.  You asked the Plan to pay for the lab testing. You say that the services should be covered. The Plan denied your request. The Plan says insufficient medical records were provided to support the claim.  The Plan must follow Medicare rules. Medicare 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. The plan made multiple requests for supporting medical records and none were provided. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81408, 81286, 81479, 81404) provided March 25, 2021.