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

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the member's oxygen levels require constant monitoring and they are unable to speak, communicate, bathe or handle basic medical necessities. The Plan denied your request. The Plan says the member does not require skilled nursing services that cannot be met in a lower level of care.
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 pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no clear documentation that the member requires daily skilled nursing or skilled therapy 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee
does not require daily nursing or therapy 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 pre-approve SNF services. Our physician reviewer
found that the enrollee does not have documented skilled nursing needs. However, the enrollee does have
documented skilled therapy needs. Daily skilled services are required to establish a maintenance program
and/or prevent deterioration of the enrollee's condition. Therefore, skilled nursing facility services are
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 SNF services have been met. The Plan must continue coverage for the SNF
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a skilled
nursing facility (SNF) admission and services.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on October 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you were not aware of the requirement of obtaining prior authorization. You say that the services were medically necessary, and the benefit should be reconsidered. The Plan denied your request. The Plan says prior authorization was required but 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 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 provided by an out-of-network provider on October 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the home ventilator (E0466).
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that there is no evidence that this equipment is indicated for the member's condition.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 home ventilator. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found medical records supplied do support that the use of a BIPAP device is a medically appropriate approach in the treatment of this enrollee with severe COPD with oxygen dependence. 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 home ventilator have been met. Therefore, we decided that the Plan has to pre-approve the home ventilator (E0466).
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 nail debridement (11720) provided on October 23, 2019.

You asked the Plan to pay for the nail debridement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 11720 is debridement of nail(s) by any method(s); 1 to 5. 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 nail debridement. Our reviewer says that CPT code 11720 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted includes a "Podiatry form", which does not include documentation of debridement being performed, therefore this procedure cannot be confirmed. 

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 nail debridement have not been met. Therefore, we decided that the Plan does not have to pay for the nail debridement (11720) provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0482) provided May 26, 2020.
You asked the Plan to pay for the lab services. You say that the tests were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
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 codes 80307 & G0482 are not supported in the medical record. Specifically, the place of
service on the claim (81, laboratory) does not match the place of service described in the records (11, office
setting). 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 (80307, G0482) provided
May 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane.
You asked the Plan to pre-approve Abraxane. You say that you would like reconsideration because the member has tolerated this medication well and has seen improvement. The Plan denied your request. The Plan says the requested regimen has no Medicare-approved cancer compendia support.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Abraxane. Our reviewer says that the Medicare approved compendia do not contain any supportive citations for the use of the requested drug formulation for the member's condition. Our physician reviewer found no literature was provided in support of the request. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided a participating provider on August 20, 2020.

You asked the Plan to waive the copayment for wound care. You say that the services you received were ineffective. The Plan denied your request. The Plan says the correct copayment has been 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 $50 copayment for outpatient surgery. 

You have been asked to pay a $50 copayment for wound care. The correct copayment has been applied to the services that were provided. Wound care falls 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 copayment for an outpatient surgery provided by a participating provider on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the alginate wound dressing provided on December 24, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee had no control over which physicians would be assigned to his case. The Plan denied your request. The Plan says the services were related to the debridement procedure.

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 A6197 is Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing. 

We looked at the file and the rules. In this case, the service at issue is a bundled service. Payment for the service is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the alginate wound dressing provided on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service provided on December 2, 2020.

You asked the Plan to pay for the telephone evaluation and management service. 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 for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.

Review of the file shows that the place of service for the telehealth visit was billed incorrectly. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home visit services provided from March 30, 2020, to April 27, 2020.

You asked the Plan to reimburse you for the home visit services. You say that you were sent home when you should have been in a skilled nursing facility. The Plan denied your request. The Plan says the services were custodial, not performed by a Medicare eligible provider, and not under the direction of a physician.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visit services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for the home visit services provided from March 30, 2020, to April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Afirma Genomic Sequencing Classifier Oncology (Thyroid) Testing provided on October 10, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing is 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 83-year-old woman with a 3.0 cm Bethesda III thyroid nodule determined to be Afirma GSC benign with a low risk of malignancy. The provided documentation contains insufficient medical records to establish medical necessity and reasonableness as defined by Medicare rules. The elements of the coverage rule are not satisfied. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Afirma Genomic Sequencing Classifier Oncology (Thyroid) Testing provided on October 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), the bitewings - four radiographic images (D0274), and the periodic oral evaluation (D0120).
You asked the Plan to pay for the dental services (D1110, D0274, D0120). You say that the requested services were necessary. The Plan denied your request. The Plan says you have a $0 copayment up to the $2,000 allowance for covered dental services. You pay 100% of charges beyond the $2,000 allowance.
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. The Plan has submitted evidence that you exhausted the $2,000 benefit prior to date of the requested services. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), the bitewings - four radiographic images (D0274), and the periodic oral evaluation (D0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for myChoice CDx testing provided on October 14, 2020.

You asked the Plan to pay for genetic testing. You say that this test is covered by Medicare and should be paid. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the record does not show how the enrollee can to the ordering physician or whether this testing was medically necessary.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due for a claim.

We looked at the file and Medicare rules. No medical records were submitted to support the lab order and testing performed. The plan requested this information, but it was not provided. Without this information, you have not furnished sufficient information to determine whether this testing was medically necessary or should be covered based on Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for myChoice CDx testing provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15734-80 and 15734-51) provided on November 2, 2020.
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
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 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 muscle, myocutaneous, or fasciocutaneous flap. Our reviewer says that CPT codes 15734 and 15734 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that a muscle, myocutaneous, or fasciocutaneous flap; trunk was performed on November 2, 2020, therefore 15734 80 and 15734 51 cannot be validated. 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 muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15734-80 and 15734-51) provided on November 2, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 pre-approve SNF care. Our reviewer says that the
services are medically necessary. Our physician reviewer found the enrollee does have documented skilled
nursing needs, receiving daily treatments for COPD and possible early pneumonia. The enrollee does have
documented skilled therapy needs, having just been advanced to full weight bearing following recent
trauma. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration
of the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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.