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

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 10, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethoracic endograft placement (5958, 75959, 75956, 75957,33880, 33881, 37252, 33883, 33884, 33886, and 33889).You asked the Plan to pre-approvethoracic endograft placement. You say that the enrollee is at risk without this procedure.The Plan denied your request. The Plan says this 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 pre-approve thoracic endograft placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the patient has a recent descending (Type B) aortic dissection. Standard management for this diagnosis includes blood pressure management and surveillance with serial imaging to assess for progression. thoracic endograft placement would be considered only if there is documentation of continued pain, progression of periaortic hematoma, malperfusion syndrome, refractory hypertension or aortic expansion since the index event. The records do not support any of these complications.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thoracic endograft placement have not been met.Therefore, we decided that the Plan does not have to pre-approvethoracic endograft placement (5958, 75959, 75956, 75957,33880, 33881, 37252, 33883, 33884, 33886, and 33889).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for electric stimulation therapy (G0283) provided on January 27, 2020.You asked the Plan to pay for the electric stimulation therapy. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says the service was billed without a therapy modifier.The Plan must follow Medicare rules. Medicare rules say that claims containing any of the "always therapy" codes must have one of the therapy modifiers appended (GN, GO, GP).We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Specifically, CPT code G0283 is a "always therapy" code. This means that CPT code G0283 must be billed with a GN, GO or GP modifier.Therefore, we decided that the Plan does not have to pay for electric stimulation therapy (G0283) provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a
power wheelchair because you are unable to ambulate long distances without needing to sit and rest. The Plan
denied your request. The Plan says the evaluation documentation states you can walk without the need of a
cane or walker.
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.
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your
condition can be improved by a walker or cane. Your assessment shows you are a functional ambulator within
your home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you were so dizzy that you were unable to sit up or stand. You and your wife called 911 and an ambulance was dispatched. You say that the responders evaluated you and told you that you needed to go to the emergency room. You stated that they told you that you could either go by ambulance or your wife and neighbor could take you by car. You say that you chose to go by car and ended up being in the hospital for two and a half weeks. You asked the Plan to reconsider providing coverage for the ambulanceservices. You say that you live in a rural area and you do not understand why the services were denied.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown on tooth #29 (D2740).You asked the Plan to pre-approvea crown on tooth #29. You say that the services are necessary.The Plandenied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 a crown on tooth #29. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the long term prognosis of the tooth would be considered poor if no further procedures were performed to make the mesial margin accessible. Given the depth of the area seen on the mesial aspect of the provided x-ray, there would not be a finding of medical necessity until after the area was made restorable by repositioning of the bone.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of a crown on tooth #29 have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown on tooth #29 (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires frequent physician monitoring, and rehab therapy to return to his prior level of function.The Plan denied your request. The Plan says the enrollee does not require intensive, complex, interdisciplinary therapy in the acute inpatient setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 you were at minimal assist for bed mobility, and at standby assist with ambulation using a walker. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from physical and occupational therapy, but the documentation does not support that your functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF.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 decidedthat the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegym quality exercise equipment (E1399) that includes a treadmill, stationary bike, elliptical, and weight resistance pulley and lever.You asked the Plan to pre-approvethe exercise equipment. You say that due to COVID you are unable to go to your normal gym and have gained 15 pounds since the pandemic started. You have an empty wing in your house where you can place all of the equipment.The Plan denied your request. The Plan says these items are 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 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 pre-approvegym quality exercise equipment (E1399) that includes a treadmill, stationary bike, elliptical, and weight resistance pulley and lever.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that previously the Plan has paid for specialized shoes and they should pay for them in this instance as well. You say that you have two different shoe sizes and your leg bones are completely fused due to an accident. You stated that this impacts your gait and has caused injury to your back. You say that you are prone to falling because you cannot properly keep your balance and you fear that you may have to go to the emergency room again due to your balance issues. You asked the Plan to reconsider providing coverage for the requested foot orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 13, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on December 13, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says they did not received documentation to support the medical necessity of a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Euflexxa. Our reviewer says that the criteria for coverage of the requested drug have not been met. Our physician reviewer found the Plan requires a trial of drugs Monovisc and Orthovisc first before they will approve the requested drug. The medical records provided do not show that the enrollee has tried and failed the required drugs. There is no indication that the plan's required drugs would be less effective or likely to have an adverse effect on the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee's feet are currently very swollen. You say that the hospital left the enrollee sitting in a chair for days. You say that the enrollee is not able to walk at this point and needs physical therapy to get her strength back. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have 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 above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of an inpatient psychiatric stay for the
enrollee.
You asked the Plan to pre-approve the additional days. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is able to take care of activities of daily living, and is tolerating
their medicine.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 additional days. Our reviewer says
that the requested additional days are not medically reasonable or necessary. Our physician reviewer found it is
not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not
have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was
compliant with treatment, while not showing any acute threats to safety. It does not appear medically necessary
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of
care beyond the dates in question.
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 additional days have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional days of an inpatient psychiatric stay for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from October 1, 2019 through October 16, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you want coverage past the first 20 days. You say that days 21-100 should be covered. 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 $0 copayment per day for days 1-20 and a $172 copayment for days 21-100 for Medicare-covered SNF stays. Cost-sharing applies to day of discharge. The enrollee has been asked to pay a $1,204 copayment for the SNF stay.
Date of Service
SNF Days
Number of Days
Copayment
Member Liability
September 20, 2019-September 30, 2019
1-11
11
$0/day
$0
October 1, 2019- October 9, 2019
12-20
9
$0/day
$0
October 10, 2019- October 16, 2019
21-26
7
$172/day
$1,204
TOTAL:
$1,204
The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from October 1, 2019 through October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on February 28, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that when you made the appointment, you
had asked for a cleaning. You also say that a deep cleaning was mentioned, and you refused. The Plan denied
your request. The Plan says this service is not a covered benefit.
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. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance provided on February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is needed for per-operative planning. The Plan denied your request. The Plan says the records show the enrollee had the same test or one like it on June 3, 2020. The Plan says that the records do not show why the previous test did not give the doctor the information needed for surgery.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the enrollee already had a CT scan performed. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2019.
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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehome health physical therapy services.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is 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 the services. 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 you do not have documented skilled therapy needs. You are functionally mobile with minimal supervision. Home skilled therapy is not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs can be provided at a lower level of care (ex. outpatient therapy, home exercise program).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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehome health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360/Next Generation comprehensive testing provided to the enrollee on March 9, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says the testing requires use of CPT 81479.
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 81479 is "unlisted molecular pathology procedure." We find that the denied testing is not supported in the medical record. Specifically, this testing must be billed with CPT 81479. The claim does not show this. 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 Guardant360/Next Generation comprehensive testing provided to the enrollee on March 9, 2020.