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

We decided that the Plan does not have to pay for the rest home visits provided from June 3, 2020, to October
14, 2020, by an OON provider.
You asked the Plan to pay for the practitioner services. You say that the provider was not aware that the
enrollee had changed plans until November 2020. The Plan denied your request. The Plan says there was no
referral or prior authorization was not obtained before the services were rendered to the enrollee. The Plan says
that a referral can be obtained from the enrollee's Primary Care Provider (PCP).
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 rest home visits provided from June 3, 2020, to
October 14, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 8, 2020, to October 9, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you never paid in the past and this was just an overnight surgery. 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 $200 copayment for day 1 and a $25 copayment for days 2-5 for inpatient hospital care. You have been asked to pay a $200 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided from October 8, 2020, to October 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen without contrast (74150) provided on December 3, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as the place of service was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, the place of service code was billed incorrectly as it should indicate or reflect the actual setting where the enrollee received face-to-face service. Place of service code 22 was billed indicating treatment provided at an outpatient hospital facility. However, the record indicates that the enrollee received inpatient hospital care on this date of service. The claim should have been billed with place of service code 21. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen without contrast (74150) provided on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 1, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary for the enrollee. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 1, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for unlisted molecular pathology procedure (CPT code 81479) provided to the enrollee on October 23, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says that there is no clinical documentation of the enrollee's stage of cancer nor of the enrollee's decision to pursue treatment. The Plan states neither the guideline criteria nor the standard of care criteria are not met due to insufficient documentation.

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 the file, and Medicare rules. The Plan used Medicare's Nation Coverage Determination (NCD) 210.14 in their denial rationale which does not apply to this case. Furthermore, the additional information medical records clearly explain the physician's intent for the testing and the results use for ongoing treatment. Therefore, we decided that the Plan has to pay for unlisted molecular pathology procedure (CPT code 81479) provided to the enrollee on October 23, 2020. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says no clinical information was provided to support any medical need for a continuous glucose monitor, including documentation of need for insulin, number of injection, A1c levels, prior control or reason for the request.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee is only using insulin once a day. The elements of the coverage rule 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 28, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 September 28, 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 for the ambulance services provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and the extractions (D7210 x 2) provided on November 12, 2019.
You asked the Plan to pay for the dental services. You say that you were not aware of the providers recent network status change prior to receiving the services. You also say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that care rendered by a provider that is not part of our supplemental dental network 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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and the extractions (D7210 x 2) provided on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says arterial oxygen saturation was found to be above 88%.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found the original qualifying oxygen saturation was done nearly 3 years ago. The enrollee is questioning whether oxygen is still necessary, and is not using it with activity. Testing for oxygen need should be repeated. For now, supplemental home oxygen is considered not 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen system for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel testing provided on October 22, 2020.
You asked the Plan to pay for the services provided. You say that the testing will guide appropriate medical management of the enrollee The Plan denied your request. The Plan says the testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services provided. Our physician reviewer found that the enrollee has diagnoses of prostate cancer and metastatic adenocarcinoma of the breast. The oncologist planned to send the enrollee's tissue for further genetic profiling with Tempus, and to consider genetics consultation. The Tempus gene panel is a targeted panel of 648 genes. It has not been demonstrated that the gene panel would impact the management and outcome of the enrollee in this case. Therefore, the Tempus gene panel testing has not been shown to be medically reasonable and 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel testing provided on October 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you are still in a lot of pain. The Plan denied your request. The Plan says the course of antibiotics has been completed and you no longer require daily skilled therapy.
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. Continued SNF services beyond April 7, 2021 were requested. 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 continued services. Our physician reviewer found that you completed the course of intravenous antibiotics. Your abscess site is reported to be healed. You are walking with a wheeled walker with minimal assistance and are at a minimal assist to contact guard assist level for transfers and activities of daily living. You are reported to be medically stable for discharge. You do not require skilled nursing or therapy services on a daily basis in a 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second diagnostic medial branch blocks.
You asked the Plan to pre-approve second diagnostic medial branch blocks. You say that you would like reconsideration because this service is medically necessary and provides the best chance of achieving improvement. The Plan denied your request. The Plan says the records show that the member did not have any relief from the first diagnostic medial branch blocks at these levels.
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 second diagnostic medial branch blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member failed to get meaningful pain relief from the first set of diagnostic medial branch blocks. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of second diagnostic medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve second diagnostic medial branch blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialty absorptive dressing (A6252).
You asked the Plan to pre-approve the specialty absorptive dressing. You say that you would like reconsideration because you have been given granufoam to help with healing. The Plan denied your request. The Plan says you do not meet coverage criteria because you have a partial thickness wound.
The Plan follows Medicare rules. Medicare rules say that specialty absorptive dressings are covered when used for moderately or highly exudative full thickness wounds. 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 specialty absorptive dressing. Our reviewer says that the criteria per the LCD have not been met for the requested specialty absorptive dressing. Our physician reviewer found there is not evidence that you have a moderate of highly exudative full thickness wound. 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 specialty absorptive dressing have not been met. Therefore, we decided that the Plan does not have to pre-approve specialty absorptive dressing (A6252).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, panoramic x-ray, bitewing x-rays, and comprehensive oral evaluation provided on October 1, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis, panoramic x-ray, bitewing x-rays, and comprehensive oral evaluation. You say that you contacted the Plan prior to this appointment and were told that this provider was in-network. The Plan denied your request. The Plan says these services were rendered OON, and the $187.50 applied correctly to your liability per the EOC. The Plan also says that you contacted them on November 21, 2020 regarding the network status of the treating provider and were advised that this provider is OON.
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, you are responsible for a 50% coinsurance for covered preventive and comprehensive dental services that are rendered OON. Therefore, we decided that the Plan does not have to pay for the prophylaxis, panoramic x-ray, bitewing x-rays, and comprehensive oral evaluation provided on October 1, 2020 by an OON provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do have documented skilled therapy needs. You are functioning below your baseline. You have not yet been shown to have reached a plateau in function from therapy. Daily skilled services are required to establish a maintenance program and/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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.