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

We decided that the Plan does not have to pay for the Skilled Nursing Facility services provided on October 1, 2019,through October 27, 2019.

You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare does not pay for accommodations on the day of discharge or death.

The Plan must follow Medicare rules. Medicare rules say that the day of discharge, death, or a day on which a patient begins a leave of absence, is not counted as a utilization day. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility services have not been met. Specifically, the record indicates that the member received Skilled Nursing Facility services for 26 days as the day of discharge is not counted as a utilization day. The claim was billed with 27 units. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility services provided on October 1, 2019,through October 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on October 19, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services denied correctly.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 88305 is 16. You billed 18 units of this code, exceeding the MUE. The records show that 16 units of the service at issue were paid for by the Plan. 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 further pay for the pathology services provided on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Olmesa Medox tablets.

You asked the Plan to pre-approve Olmesa Medox tablets. You say that this is medically necessary, and the enrollee has failed other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 pre-approve Olmesa Medox tablets.

Benefits for Olmesa Medox tablets 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 acupuncture services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this has been ordered for relaxation of the neck, which is not a covered diagnosis.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. The file shows that this request is for relaxation of the neck for a surgery. This not a covered diagnosis for acupuncture, which is only covered for lower back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the biological materials to aid in soft and osseous tissue regeneration (D4265) and the partial ostectomy/sequestrectomy (D7550 x 3) provided on January 25, 2021.

You asked the Plan to pay for the dental services. You say that you had root canals done which resulted in toxins in your gums. You say that you feel these toxins are causing other health issues. You also say that these services were truly medical in nature. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan also says they are not listed as covered services.

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 biological materials to aid in soft and osseous tissue regeneration (D4265) and the partial ostectomy/sequestrectomy (D7550 x 3) provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 25, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for a
laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation
setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to
pay for the drug testing rendered on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home care services (CPT 99336) provided to the enrollee on August 13, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the incorrect place of service was billed.

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 99336 is "Established Patient Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services." 

We asked our coding 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the virtual visit documents a virtual visit was performed in the enrollee's residence which is an assisted living facility. Therefore, place of service 12 would be incorrect to report. There is a more appropriate code to report for this service. 

We looked at this coder'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 pay for home care services (CPT 99336) provided to the enrollee on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for surgical services.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are orthopedic surgeons available in-network.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for surgical services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve these services. You say that lack of sleep is affecting your quality of life.
The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific criteria are
met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have
insomnia but the records do not include a complete sleep history or records from the sleep medicine consultant.
You have no symptoms suggestive of narcolepsy. The records do not support that the sleep study is reasonable
or medically necessary at this 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on January 11, 2021.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you believe this service should be covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray on January 11, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neurostimulator (E0745) provided to the enrollee on September 3, 2020.

You asked the Plan to pay for the neurostimulator. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The rules rules say that DME supplies must be provided with a proof of delivery. 

In this case, the CPT Code Manual definition of code E0745 is "Neuromuscular stimulator, electronic shock unit."

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 neurostimulator. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation includes a physician order dated February 29, 2020 with an office visit, however, documentation does not include a proof of delivery.

We looked at this physician's review, the file, and Medicare rules. The required documentation pertaining to the proof of delivery of these supplies was not provided. Based on this information, we decided that Medicare rules for coverage of the neurostimulator have not been met. Therefore, we decided that the Plan does not have to pay for a neurostimulator (E0745) provided to the enrollee on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered when being requested for use outside the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve mandible reconstruction (21244) and a mandible bone graft (21215).

You asked the Plan to pre-approve mandible reconstruction and a mandible bone graft. You say that this is a medical service. The Plan denied your request. The Plan says that this is a non-covered dental service.

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. The rules also say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth (gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process).

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 mandible reconstruction and a mandible bone graft. Our reviewer says that the requested services are not dental in nature and are considered medically reasonable and necessary in this case. Our physician reviewer found the patient was diagnosed with osteomyelitis of the mandible (a medical condition), which requires excision and debridement of the diseased bone. Mandibular reconstruction and bone grafts are medically reasonable and necessary to return the patient to normal function.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mandible reconstruction and a mandible bone graft have been met. Therefore, we decided that the Plan has to pre-approve mandible reconstruction (21244) and a mandible bone graft (21215).

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: 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's care can be provided in the current hospital.

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 the patient appears to be unstable with hypotension, pleural effusions, and vent dependency at this time, requiring additional short-term acute care services which can be safely administered at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemodenervation provided on August 10, 2020.

You asked the Plan to waive the copayment for the chemodenervation. You say that you previously paid $35 for this procedure and you want a refund of $65. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. 

You have been asked to pay a $100 copayment for the chemodenervation. The chemodenervation falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The chemodenervation is considered a surgical service that was billed by the hospital. 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 chemodenervation provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 27, 2020.

You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on the records submitted and would like for this service to be paid at the member's in-network benefit. The Plan denied your request. The Plan says there is an appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0152) for the billed 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. 

In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the record. Specifically, the record indicates that this service was rendered in a home setting. There is a more appropriate CPT code for the rendered service. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D5810).

You asked the Plan to pre-approve the services. You say that this is medically necessary, as you cannot eat well. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D5810).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nurse facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary at this time. The Plan denied your request. The Plan says you needs can continue to be met at the current acute care setting.
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 the enrollee is a 92-year-old female with a past medical history of hypertension, atrial fibrillation, chronic obstructive pulmonary disease and chronic kidney disease who has been in a long-term acute care hospital since March 29, 2021, after suffering a cardiac arrest. Although there is documentation that the patient requires skilled nursing services, this patient does not require skilled therapy services. While the skilled nursing services would be necessary on a daily basis, continued care in the long-term acute care hospital is appropriate until the patient is stable to transfer to a lower level of care and the health plan has stated that continued care in the long-term acute care hospital will be 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nurse facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular testing provided on October 20, 2020.

You asked the Plan to pay for the Guardant360 molecular testing. You say that you would like reconsideration because this testing is a Medicare covered benefit. The Plan denied your request. The Plan says to report a comprehensive genomic profile, service providers should use CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEXZ-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes.

The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report Guardant360 molecular testing. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 molecular testing. have not been met. Specifically, this claim has not been billed correctly for Guardant360 testing. Per Medicare, to report this testing, providers must use one unit of 81479. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular testing provided on October 20, 2020.