Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a
participating provider on July 21, 2020
You asked the Plan to waive the copayment for physician services. You say that you had a three-minute phone
conversation. You say that all they did was read you test results. 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 $15
copayment for physician/practitioner services/standard primary care physician.
You have been asked to pay a $15 copayment for physician services. Telemedicine calls are subject to
copayments; therefore, the correct copayment has been applied. Physician services falls within the
physician/practitioner services/standard primary care physician 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 physician services provided by a participating provider on July 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a new patient office visit (99205) provided on March 28, 2021.
You asked the Plan to pay for a new patient office visit. You say that this was billed correctly. The Plan denied your request. The Plan says the enrollee was not considered a new patient at the time of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the phrase "new patient" should be interpreted to mean a patient who has not received any professional services from the physician or
physician group practice (same physician specialty) within the previous 3 years.
In this case, the CPT Code Manual definition of code 99205 is office or other outpatient visit for the evaluation
and management of a new patient, which requires a medically appropriate history and/or examination and high
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on
the date of the encounter.
We find that CPT code 99205 is not supported in the medical record. Specifically, the record shows that the
enrollee was treated by a physician in the same group practice and specialty on March 8, 2021, meaning that it
is not appropriate to bill the services at issue as a new patient visit. Based on this information, we decided that
Medicare rules for coverage of a new patient office visit have not been met. Therefore, we decided that the Plan
does not have to pay for a new patient office visit (99205) provided on March 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF
admission is not medically necessary.
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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that based on review of the available
limited records, the enrollee does not meet the CMS coverage criteria for an admission to a SNF due to the lack
of documentation substantiating a need for nursing care, and no supporting documentation of therapies to
require daily therapies in an inpatient setting when the enrollee is not participating in therapies.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the circulating tumor cell assay (CTC) and circulating tumor DNA (ctDNA) assay provided on December 28, 2020.
You asked the Plan to pay for the CTC. You say that this test was provided in good faith. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. CTC essays are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the circulating tumor cell assay (CTC) and circulating tumor DNA (ctDNA) assay provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 30, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim denied due to the Medicare Secondary Payor rules of medical being the payor of last resort when third party liability is identified. A remittance advice dated March 14, 2021 was sent to the provider. The enrollee was injured in a restaurant. This claim needs to be filed with restaurants liability insurance before the Plan will process claims for payment. The enrollee is aware of this but is not responding to the Plans claim information requests.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer or where appropriate a third part or liability payor. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has provided you as the provider and the enrollee with the next steps required to file this claim appropriately with the restaurant in which the enrollee was injured. As the secondary insurer, the Plan cannot be held responsible for this service until the third-party payor has addressed this claim. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on January 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical blend provided during a Sanexas device treatment on October 8, 2020, billed with codes J1955, J3411, J3415, and J3490.
You asked the Plan to pay for the nutria-pharmaceutical blend. You say that these services should be covered. The Plan denied your request. The Plan says this is not coded correctly.
The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Therefore, we decided that the Plan does
not have to pay for the nutria-pharmaceutical blend provided during a Sanexas device treatment on October 8, 2020, billed with codes J1955, J3411, J3415, and J3490.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acoustic wave therapy.
You asked the Plan to pre-approve acoustic wave therapy. The Plan denied your request. The Plan says this is an experimental service.
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 acoustic wave therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that investigation is still needed through larger and more standardized trials prior to widespread acceptance. Therefore, this procedure is considered investigational/experimental at the present time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acoustic wave therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve acoustic wave therapy.
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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted following a myocardial infarction and acute hypoxic respiratory failure with
pneumonitis. The enrollee is improving. The enrollee continues to receive acute care services, and these have
not been denied. The medical record does not indicate that the enrollee requires services that he is not
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are
not satisfied. The requested service cannot be recommended.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on April 3, 2021, to April 4, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that your doctor was unavailable, so you went to the ER. 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 $120 copayment for emergency care/in-network/emergency services. You have been asked to pay a $120 copayment for an emergency room visit. Since an emergency room care was provided, the correct copayment has been applied. An emergency room visit falls within the emergency care/in-network/emergency 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 emergency room visit provided by a participating provider on April 3, 2021, to April 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 17, 2020.
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 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 the laboratory services are not supported in the medical record. Specifically, the services rendered
should be billed with one code, code 81479. The documentation shows that various codes were billed for the
services rendered, which is incorrect. Based on this information, we decided that Medicare rules for coverage
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on December 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you would benefit from SNF care. The Plan denied your request. The Plan says you have not had a change in function that needs daily skilled 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted on 8/7/2021 with a right leg wound with cellulitis. She was treated in the hospital with antibiotics and improved. She is weak and deconditioned and is working with physical and occupational therapy. She is walking 60 feet with a walker with stand-by assistance and is stand-by assist for transfers and activities of daily living. She is reported to be medically stable for discharge. There is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. While there is a documented need for skilled therapy services, these are not required on a daily basis. As a practical matter, these services on not required on an inpatient basis in the SNF setting. 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 admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that because this enrollee has a COVID diagnosis, there is no skilled nursing facility that will accept them. The enrollee requires additional respiratory care that cannot be provided at a nursing home level of care, and the beds are needed to help other patients in the enrollee's current acute setting. The Plan denied your request. The Plan says that the criteria for an IRF are not met.

The Plan must follow Medicare rules. Medicare has stated that during the COVID-19 pandemic, inpatient rehabilitation facilities may accept patients from an acute-care hospital experiencing a surge, even if the enrollee does not require rehabilitation care. 

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 considered medically reasonable and necessary based on Medicare's updated guidelines during the current Public Health Emergency. Our physician reviewer found the enrollee appears to meet medical necessity criteria as they have no more reasonable location to receive care due to their diagnosis of COVID-19. This enrollee would be appropriate for a short-term stay at an IRF as they are stable enough to be transferred from the current facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Medicare rules for admission to an IRF have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on April 27, 2021.
You asked the Plan to waive the copayment for an office visit. You say that copayments are waived for the year and you have not had to pay a copayment for previous visits. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $15 copayment for primary care provider visits. You had an office visit on April 27, 2021. Office visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided February 24, 2021.
You asked the Plan to pay for the orthoses. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the provider was excluded from participation in federal programs at the time services were rendered.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported crown (D6066) provided on March 31, 2021.

You asked the Plan to pay for the implant supported crown. You say that you would like to know exactly what your plan covers. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 implant supported crown (D6066) provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950) and gingivectomy or gingivoplasty (D4212) provided on April 19, 2021.
You asked the Plan to pay for the core buildup (D2950) and gingivectomy or gingivoplasty (D4212). You say that the doctor deemed the work essential to preserve chewing and in mouth activities. You say that you are appealing the denial of at least partial payment for the services rendered. The Plan denied your request. The Plan says the services are not covered benefits.
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 core buildup (D2950) and gingivectomy or gingivoplasty (D4212) provided on April 19, 2021.
Your complaint about being tricked is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) provided on August 12, 2020.

You asked the Plan to pay for needle electromyography. You say that this was necessary for the safety of the patient. The Plan denied your request. The Plan says this is not documented in the records.

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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. 

We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documentation of this service being performed. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 23, 2021.
You asked the Plan to pay for lab testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not contain a signed physician order or authenticated medical records documenting that the enrollee's treating physician intended for this testing to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 23, 2021.