Persius/hicric huggingface dataset:
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 SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says rules for 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 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 that the member has stabilized medically and
is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy
services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care.
Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member
does not have any parental medication; complex wound care or nutrition given via a feeding tube. He is
medically stable without any acute exacerbations of chronic medical problems. His physical function is at or
near his baseline and he can receive services 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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on November 10, 2020, and November 23, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you feel that you should not be held responsible for these charges. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on November 10, 2020, and November 23, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided from July 29, 2020, to September 23, 2020.

You asked the Plan to waive the coinsurance for chemotherapy. You say that you disagree with the charges because the physician put you at risk of COVID-19 and you are unhappy with the care you received. 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 20% coinsurance for Medicare Part B prescription drugs. 

You received chemotherapy from July 29, 2020, to September 23, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart provided.

The total amount you owe is: $2,455.17. 

You have been asked to pay the total coinsurance amount of $2,455.17 for chemotherapy. Chemotherapy falls within the Medicare Part B prescription drugs 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 chemotherapy provided from July 29, 2020, to September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections for back pain.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the use of these injections is unproven.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this would be an experimental and investigational use for this injection. There is no evidence that it works for sciatica. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections for back pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four localized deliveries of antimicrobial agents (D4381 x4) and two gingival irrigations (D4921 x2) provided on December 18, 2020.

You asked the Plan to pay for the localized deliveries of antimicrobial agents and gingival irrigations. You say that you feel that you should not be held responsible for these charges. The Plan denied your request. The Plan says the localized deliveries of antimicrobial agents are not permitted on the same date of service as other procedures billed. The Plan also says that gingival irrigation is not covered.

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, gingival irrigation (D4921) is not among those covered under this benefit. The contract says that localized delivery of antimicrobial agents (D4381) cannot be used the same day as scaling and root planing (D4341 or D4342). The record shows that you received two scalings and planings (D4341 x2) on December 18, 2020, and the localized delivery of antimicrobial agents (D4381) could therefore not be used. Therefore, we decided that the Plan does not have to pay for the four localized deliveries of antimicrobial agents (D4381 x4) and two gingival irrigations (D4921 x2) provided on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) assay provided on April 27, 2020.

You asked the Plan to pay for the thyroid stimulating hormone (TSH) assay. 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 payable.

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 thyroid stimulating hormone (TSH) assay 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 thyroid stimulating hormone (TSH) assay provided on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit and nail debridement provided by an out-of-network provider on September 7, 2020.

You asked the Plan to pay for the home visit and nail debridement. You say that authorization was impossible with the incorrect insurance information. You say that the patient required the medical care received and the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit and nail debridement provided by an out-of-network provider on September 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine and administration charge for December 10, 2020.

You asked the Plan to pay for the Tdap vaccine and administration charge. You say that the Plan should pay this claim. The Plan denied your request. The Plan says these vaccines are not covered under your Medicare Part B drug benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine and administration charge. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine and administration charge. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine and administration charge for December 10, 2020.

Benefits for the Tdap vaccine and administration charge may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy. The Plan denied your request. The Plan says that the Plan may authorize referrals to out of-network providers in limited situations, including when services meeting the standard of care are not available within the provider network, and when emergent or urgently needed out-of-network care has been provided.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on June 18, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on June 18, 2020.
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 in this case the enrollee was admitted with sternal wound infection following recent heart bypass surgery. The enrollee continues to receive acute care services that have not been denied. The medical record does not indicate that the enrollee requires services that are currently being denied but that would be available at the LTACH facility. The elements of the coverage rule are not satisfied. The requested service is not 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on January 4, 2021.
You asked the Plan to pay for the hearing aids. You say that due to the current medical condition, you were not
able to get an appointment with in-network providers, so you had to go out-of-network. The Plan denied your
request. The Plan says hearing aids are covered when rendered by the Plan's participating hearing aid provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only provided by the Plan's hearing aid provider.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's
hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 7, 2021 and January 25, 2021.

You asked the Plan to pay for the home visits. You say that services were provided due to a contract with the assisted living facility. You say that the patient has changed plans to avoid denials and the claim should be reconsidered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 7, 2021 and January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 5, 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 payable.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 

We find that CPT code G0483 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 patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates 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 G0483 provided on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of excessive skin and tissue beneath the skin (CPT code 15839).
You asked the Plan to pre-approve the surgery. You say that after your double mastectomy you have excess skin which has pushed your arm in an unnatural position, and over time this has caused an impingement on your shoulder. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Excision of Excessive Skin surgery following mastectomy is considered a cosmetic surgery and is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve removal of excessive skin and tissue beneath the skin (CPT code 15839).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, bone replacement graft for ridge preservation, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and adjunctive procedure provided on November 27, 2020 by an OON provider.
You asked the Plan to pay for the extraction, bone replacement graft, deep sedation/general anesthesia, and adjunctive procedure. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider.
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 received OON. Therefore, we decided that the Plan does not have to pay for the
extraction, bone replacement graft for ridge preservation, first 15 minutes of deep sedation/general anesthesia, each subsequent 15 minute increment of deep sedation/general anesthesia, and adjunctive procedure provided on November 27, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on September 18, 2020.

You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your request. The Plan says this code is not paid under OPPS.

The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 14X and 13X without condition code 41) are subject to the Outpatient Prospective Payment System (OPPS). An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged.

We looked at the file and Medicare rules. The service at issue was billed on bill type 131, meaning it is subject to OPPS. Code 99214 has a status indicator of "B," indicating it is not paid under OPPS. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on September 18, 2020.