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

We decided that the Plan does not have to pay for the tissue exam provided by an out-of-network provider on October 30, 2020.
You asked the Plan to pay for the tissue exam. You say that the healthcare provider sent the specimens to your laboratory for analysis. You say that the service billed was referred by an authorized provider so the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 tissue exam provided by an out-of-network provider on October 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (CPT code(s): A0425 and A0426) provided to the enrollee on September 18, 2020, by a non-participating provider.

You asked the Plan to pay for ambulance services. You say that the claim should be paid. The Plan denied your request. The Plan says this enrollee was inpatient.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. The enrollee's claims history indicates they were in an inpatient hospital status, which shows an admission date of September 17, 2020 and discharge date of September 23, 2020. The rules say that ambulance services used for the transportation of a hospital inpatient to another facility is considered part of the inpatient admission, and are not separately payable. Therefore, we decided that the Plan does not have to pay for ambulance services (CPT code(s): A0425 and A0426) provided to the enrollee on September 18, 2020, by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81286, 81407, 81408, 81479) provided July 28, 2020.
You asked the Plan to pay for the lab testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel. We looked at the file and Medicare rules. The cardiovascular risk assessment testing is not a covered benefit. 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 (81286, 81407, 81408, 81479) provided July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided September 22, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the code billed.
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 pay for the shoulder elbow wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. 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 shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960) provided September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 6, 2021.
You asked the Plan to pay for the dental service. You say that you feel that this service should be covered. The Plan denied your request. The Plan says full mouth x-rays are covered once every 36 months. The Plan says that the frequency limit for this service 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 full mouth x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a full mouth x-ray that you received on February 12, 2018, less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 6, 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of
care.
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: 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
needs can be met at an alternate level of care.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig provided on September 14, 2020.
You asked the Plan to pay for the wig. You say that you are recently off chemotherapy and due to this you lost your hair. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The health plan contract says non-covered items include, but are not limited to: wigs. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the wig provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601) for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a current sleep study to define the physiological issues at hand.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been diagnosed with obstructive sleep apnea (OSA), and according to the medical records has been on CPAP regularly in the past. A replacement device is now needed. However, the records only include the report of a single sleep study from 6/10/14, which did not show OSA. Therefore, a new device is considered not medically necessary. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound closure provided on October 26, 2020.
You asked the Plan to waive the copayment for the wound closure. You say that your stitches broke open and you needed a second surgery. You say that you shouldn't pay a second copayment. The Plan denied your request. The Plan says the copayment 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 $310 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $310 copayment for the wound closure. The wound closure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the procedure was performed. 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 wound closure provided on October 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321)
You asked the Plan to pay for Guardant360 testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. To report a CGP service, test providers should use CPT code 81479. We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81270, 81272, 81275, 81293, 81310, 81311, 81314, and 81321 are not supported in the medical record. Specifically, the testing at issue is a CGP service and should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (84443, 80061, 36415, 80053) provided on October 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 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 laboratory services (84443, 80061, 36415, 80053) provided on October 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0813).

You asked the Plan to pre-approve a group 1 power operated vehicle. You say that you need this item due to
medical necessity. The Plan denied your request. The Plan says they do not know if enrollee can safely operate
wheelchair in home.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 a group 1 power operated vehicle. Our
reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found
the documentation indicates that you have a mobility deficit, but it is not clear exactly how much it impairs
MRADLs in the home and why you cannot use a walker or manual wheelchair. The office note states a manual
wheelchair is not optimal due to limb weakness and that a "a cane and walker are not sufficient to help with
mobility." It is not clear why a walker is not sufficient to help the patient and the patient's full range of motion
and reported strength conflicts with the statement that she cannot use a manual wheelchair due to limb
weakness. While the patient may have the cognitive ability to safely use the wheelchair it is not clear that the
requested power mobility deficit can be safely maneuvered in the home.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a group 1 power operated vehicle have not been met. Therefore, we decided that
the Plan does not have to pre-approve a group 1 power operated vehicle (K0813).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care provided on November 23, 2020 by an out
of network (OON) provider.

You asked the Plan to pay for the nursing care. You say that the services were medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.

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 nursing care provided on November 23, 2020
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy visits. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 additional physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the documentation does not support that the unique
skills of a professional therapist are required to safely and effectively provide treatment, or that the services can
be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a
therapist. The enrollee receives assistance currently from facility staff and can safely transfer with Hoyer. The
requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of
a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration. Therefore, the enrollee does not meet criteria for the
requested 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 additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261), the bone replacement graft (D4263), and the biologic materials to aid in soft and an osseous tissue regeneration (D4265) provided on October 2, 2020.
You asked the Plan to pay for the osseous surgery, bone replacement graft, and biologic materials. You say that your regular dentist recommended you to this provider who is in network with your plan. You say that your Medicare plan should help you with this, so you do not have to pay out of pocket. The Plan denied your request. The Plan says the services that you received are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Although the Plan offers a dental benefit in excess of Medicare coverage, implant related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261), the bone replacement graft (D4263), and the biologic materials to aid in soft and an osseous tissue regeneration (D4265) provided on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December 4, 2020, through December 8, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were told insurance covered more than what was billed. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day for days 1-5 for each in-network, Medicare-covered inpatient hospital stays. The enrollee has been asked to pay a $1,200 copayment for the inpatient stay. ($300/day x 4 days = $1,200). The inpatient stay falls within the "Inpatient hospital 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 the inpatient stay provided from December 4, 2020, through December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on April 25, 2020 to April 29, 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 procedure code 99291 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care spent on the enrollee for each billed date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on April 25, 2020 to April 29, 2020.