Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare criteria for IRF admission are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. The enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Medicare criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drugs provided from November 17, 2020, to November 18, 2020.

You asked the Plan to waive the coinsurance for the Medicare Part B drugs. You say that you should not have coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay 20% coinsurance for the Medicare Part B drugs. The Medicare Part B drugs 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 the Medicare Part B drugs provided from November 17, 2020, to November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power elevating seat (E2300).

You asked the Plan to pre-approve the power elevating seat. You say that you require this part of the wheelchair. The Plan denied your request. The Plan says a power seat elevation feature is never covered since is not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is not a covered item per the Local Coverage Policy Article. Therefore, we decided that the Plan does not have to pre-approve a power elevating seat (E2300).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee from September 24, 2020, to October 12, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the benefit limit has been reached.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from April 9, 2020, to September 23, 2020. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee from September 24, 2020, to October 12, 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 for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare criteria for transfer are not met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment for renal failure in the setting of known metastatic melanoma. The enrollee has been receiving hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available at the current facility. The enrollee can remain at the current facility until such time no acute services are required. Medicare coverage criteria are not met.

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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2020.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 genetic testing is not supported in the medical record. Specifically, these services should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovascular revascularization.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of a trial and failure of conservative treatments, such as
exercise and medications.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is substantial documentation that you have multiple etiologies for leg pain and walking limitation.
Your vascular provider recognizes this and expressly instructed you to complete the spine treatments prior to
consideration of any revascularization efforts, as you will require dual antiplatelet therapy once endovascular
treatment is initiated. This would impact your ability to get spinal treatments that may involve epidural
injections. The documentation does not support that you have completed your spine treatments.

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 Plan does not have to pre-approve endovascular revascularization.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on January 6, 2021.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.

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 $25 copayment for each Medicare-covered ultrasound at a freestanding provider. 

Review of the file shows that you had an ultrasound on January 6, 2021. You have been asked to pay a $25 copayment for the ultrasound. The ultrasound falls within outpatient diagnostic tests 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 the ultrasound you had on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing services provided on November 30, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. There are insufficient records to show that the ordered testing correlates with a specific diagnosis or treatment strategy. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing services provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110), and a partial lower denture (D5214) provided on January 19, 2021.

You asked the Plan to pay for a complete upper denture, and a partial lower denture. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 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 a complete upper denture (D5110), and a partial lower denture (D5214) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care provided on January 31, 2021.

You asked the Plan to reduce the copayment for the urgent care visit. You say that you were overcharged $15 and want to be reimbursed. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount. The Plan confirmed there was an amount overpaid which will be reimbursed or credited by the provider.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for urgently needed services at an in-network specialist's office.

You have been asked to pay a $20 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 reduce the copayment for the urgent care provided on January 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 18, 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 procedure code 95957 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). 

We find that CPT code 95957 is not supported in the medical record. Specifically, there is no documentation of
digital analysis of an EEG. 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 testing services rendered on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a diagnostic test provided by a participating provider on January 6, 2021.

You asked the Plan to waive the co-payment for a diagnostic test. You say that you were at your primary care physician's office. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 co-payment for outpatient diagnostic tests/in-network/outpatient diagnostic tests.

You have been asked to pay a $20 co-payment for a diagnostic test. A diagnostic test falls within the outpatient
diagnostic tests/in-network/outpatient diagnostic tests 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 co-payment for a diagnostic test provided by a participating provider on January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging (SCODI) rendered on December 16, 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 billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The claim was not billed with the most precise diagnosis code.

Therefore, we decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging (SCODI) rendered on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular diagnostic testing services provided on February 8, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare does not cover testing panels.

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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the molecular diagnostic testing services provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular diagnostic testing services provided on
November 11, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a panel
constitutes a single procedural 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. 

We looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the molecular diagnostic testing services provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
December 12, 2020, through January 3, 2021.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says there are no daily skilled needs.

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 pay for continuation of SNF services provided from December 12, 2020, through January 3, 2021. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She had no recurrence of her vasovagal event while toileting on December 9, 2020. Regarding rehabilitation services, the enrollee did not receive nor require any skilled therapy. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continuation of SNF services provided from December 12, 2020, through January 3, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from December 12, 2020, through January 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic imaging provided on December 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for diagnostic imaging. You say that you would like this claim paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for diagnostic imaging provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 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 decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 23,
2020.

You asked the Plan to pay for a lumbar-sacral orthosis. You say that the requested item is a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar-sacral orthosis have not been met. Specifically, the case file does not contain medical records to document the medical necessity of the requested item. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 23, 2020.