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

We decided that the Plan does not have to pay for the adjacent tissue transfer (14001) provided on August 24, 2020.

You asked the Plan to pay for the adjacent tissue transfer. 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.

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 adjacent tissue transfer. Our reviewer says that CPT code 14001 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that an adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm was performed on August 24, 2020, therefore this service cannot be verified.

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 adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14001) provided on August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on June 22, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 remains 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. We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2019.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 30, 2019.
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 you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the current acute care hospital can provide acute care services until the member's condition allows transfer to an alternate level of care.
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 the short-term acute care hospital can provide for all of the member's present inpatient care needs and the health plan has stated that continued care in the short-term acute care hospital will be covered. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on December 4, 2020 by a non-Plan provider.
You asked the Plan to pay for the endodontic therapy. You say that you believe this service should be covered. The Plan denied your request. The Plan says you self-referred to a non-Plan provider for non-emergency services. The Plan also says that prior authorization was not obtained.
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 covered when they are provided by anyone other than your assigned dentist. Therefore, we decided that the Plan does not have to pay for the endodontic therapy provided on December 4, 2020 by a non-Plan provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services after May 7, 2021.
You asked the Plan to pre-approve the continued SNF services. You say that you would like reconsideration because you are not ready to return home. The Plan denied your request. The Plan says the continuation of SNF services is not medically necessary because you do not require skilled 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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your 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 the continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services after May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will be able to regain function and capacity for activities of daily living. The Plan denied your request. The Plan says the enrollee does not require physician supervision at an IRF level.
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 physician reviewer found that the enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation does not support that she would meet criteria for admission to an acute inpatient rehabilitation facility. She is ambulating up to 60 feet with minimal assistance. She is near her prior level of function. The complexity of the enrollee's nursing, medical and rehab needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound and electrical stimulation services (97035 and
G0283) provided on July 11, 2020, through November 17, 2020.

You asked the Plan to pay for the ultrasound and electrical stimulation services. You say that you would like
reconsideration because you were not told these were not covered services. The Plan denied your request. The
Plan says chiropractic care other than manual manipulation of the spine is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for ultrasound and electrical stimulation services (97035 and G0283)
provided on July 11, 2020, through November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound and an MRI provided by participating provider on September 12, 2020, to October 3, 2020.

You asked the Plan to waive the copayment for an ultrasound and an MRI. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $155 copayment for outpatient diagnostic tests/radiological diagnostic services. 

You have been asked to pay a $155 copayment for an ultrasound and an MRI. The total amount you are being asked to pay is $465 ($155 (ultrasound) + $155 (ultrasound) + $155 (MRI) = $465). The correct copayments have been applied to the services that were provided. An ultrasound and an MRI falls within the outpatient diagnostic tests/radiological diagnostic 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 an ultrasound and an MRI provided by a participating provider on September 12, 2020, to October 3, 2020.
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 you would like reconsideration because the IRF admission is medically necessary in order for the member to regain strength and continue chemotherapy. The Plan denied your request. The Plan says the member's rehabilitation needs are not complex, and the member does not need to be seen by a rehabilitation doctor three times a week.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on December
21, 2020.
You asked the Plan to waive the copayment for the specialist visit. You say that you did not have the services
provided. 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 $40
copayment per visit to a specialist.
You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The medical records show
an office visit with a specialist was provided on December 21, 2020. 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 specialist visit provided on December 21, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the CARIS MI Profile.

You asked the Plan to pre-approve the CARIS MI Profile. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says that the use of this test has not been shown to improve overall treatment outcomes.

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 looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CARIS MI Profile have been met. Therefore, we decided that the Plan has to pre-approve the CARIS MI Profile.

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: 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 you would like reconsideration because the IRF care is medically necessary. The Plan denied your request. The Plan says you are near baseline and intensive rehabilitation is not medically necessary.
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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on November 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 ophthalmology services provided on November 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2391) provided on September 15, 2020.
You asked the Plan to pay for a filling. You say that you want the Plan to pay for this service. The Plan denied your request. The Plan says the service at issue is a covered benefit, however the benefit maximum had already been met before this date.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum prior to this date of service. Therefore, we decided that the Plan does not have to pay for a filling (D2391) provided on September 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 1, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The claim was billed that specimen was obtained in a laboratory, place of service 81; however, the submitted medical records indicate that the specimen was obtained in an office setting; place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and the copayment for
diagnostic radiology tests, an EKG, and a specialist office visit provided by participating providers on
November 2, 2020, to December 2, 2020.
You asked the Plan to waive the coinsurance for an injection and the copayment for diagnostic radiology tests,
an EKG, and a specialist office visit. You say that you do not agree with these charges. The Plan denied your
request. The Plan says the correct coinsurance and copayment have 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 20%
coinsurance, a $135 copayment, a $30 copayment, a $35 copayment for Medicare part B prescription drugs,
outpatient diagnostic tests/radiology diagnostic services, outpatient diagnostic tests/EKG,
physician/practitioner services/specialist services.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection, a $135 copayment for
diagnostic radiology tests, a $30 copayment for an EKG, a $35 copayment for a specialist office visit.

Date of Service - Service - Allowed Amount - Coinsurance - Copayment - Total Amount
November 2, 2020 Office Visit --- --- $35 $35
November 19, 2020 Injection $242.72 20% --- $48.54
November 19, 2020 EKG --- --- $30 $30
November 23, 2020 Ultrasound --- --- $155 $155
December 2, 2020 Office Visit --- --- $35 $35
Total Amount Being Asked to Pay: $35 + $48.54 + $30 + $155 + $35 = $321.81

An injection falls within the Medicare part B prescription drugs benefit category. Diagnostic radiology tests fall
within the outpatient diagnostic tests/radiology diagnostic services benefit category. An EKG falls within the
outpatient diagnostic tests/EKG benefit category. A specialist office visit falls within the physician/practitioner
services/specialist 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 coinsurance for an
injection copayment for diagnostic radiology tests, an EKG, and a specialist office visit provided by
participating providers on November 2, 2020, to December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services provided from January 7, 2020,
to October 20, 2020.

You asked the Plan to reimburse you for the dental services. You say that the services should be covered. The
Plan denied your request. The Plan says the services were billed incorrectly. The Plan says that a corrected
claim would need to be submitted for these services to be reconsidered. The Plan says that multiple attempts
were made to obtain a correctly claim. The Plan also says that nothing has been received.

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 care that you receive outside of
the United States is not among those covered under this benefit. The Evidence of Coverage clearly states that
only emergency services are provided worldwide. Additionally, there is no evidence that the services you
received urgent or emergent. Therefore, we decided that the Plan does not have to reimburse you for the dental
services provided from January 7, 2020, to October 20, 2020.