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

We decided that the Plan has to pay for anesthesia services (CPT 01402, CPT 64447) provided to the enrollee
on May 19, 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 that the medical records submitted do not include documentation 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 CPT code. In this case, the CPT Code Manual definition of
code is "CPT 01402:

anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty
CPT 64447:

Injection(s), anesthetic agent(s) and/or steroid

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 supported by the medical records. Our coding reviewer found the
documentation includes anesthesia report performed on May 19, 2020 and a nerve block injection given on
May 19, 2020. There was a discrepancy regarding the time of the nerve block injection. The documentation
states a "pre procedure" nerve block was given at 17:19, however, the surgery was May 19, 2020 14:20 - 16:33.
The injection would be a post-procedure.

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 been met. Therefore, we decided that the Plan has to pay for
anesthesia services (CPT 01402, CPT 64447) provided to the enrollee on May 19, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temozolomide 140mg capsule in combination with
Olaparib for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is the most promising treatment regimen at this
time. The Plan denied your request. The Plan says this regimen is not being prescribed for a medically accepted
indication.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.

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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found for patients that
progress within six months or while on treatment for extensive stage small cell lung cancer single agent therapy
is recommended. The combination of temozolomide capsule in combination with Olaparib is not FDA
approved, supported by major drug compendia, or the medical literature in phase III trials. The service is not
reasonable or 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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Temozolomide 140mg capsule in combination with Olaparib for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092, R0075) provided on December 9, 2020.

You asked the Plan to pay for the transportation and set up of the portable x-ray.. You say that you would like reconsideration because you provider traveled to the SNF to render both the technical and professional portions of the exam. The Plan denied your request. The Plan says the member was in an approved SNF stay on the billed date of service so Medicare rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.

We find that CPT codes Q0092 and R0075 are not supported in the record. Specifically, the record indicates that the member was in a Part A covered SNF stay on the billed date of service. The transportation and set up costs are subject to consolidated billing and not separately billable. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of the portable x-ray. have not been met. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092, R0075) provided on December 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy, 60 minutes (90837) provided on October 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no adequate time frame to obtain authorization for the service. The enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 individual psychotherapy, 60 minutes (90837) provided on October 1, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on
August 6, 2020.

You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you've never had to
pay for a mammogram before and you cannot afford it now. 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 $50
copayment for each Medicare-covered x-ray at an in-network outpatient hospital facility.

You have been asked to pay a $50 copayment for the diagnostic mammogram. The diagnostic mammogram
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records
show a diagnostic mammogram was performed. 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 diagnostic mammogram provided on August 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided by an out-of-network provider on December 31, 2020.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the service was provided with no adequate time to obtain authorization. You say that the records reflect the medical necessity for the service and the claim should be reprocessed for payment. The Plan denied your request. The Plan says authorization for out of network services was not 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. 

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 psychiatric diagnostic evaluation provided by an out-of-network provider on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 test provided to the enrollee on December
6, 2020.

You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The
Plan says this test should be billed with the unlisted code CPT 81479.

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 various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare
rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for
the Guardant 360 test provided to the enrollee on December 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 22, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 28, 2021 by an OON provider.

You asked the Plan to pay more for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you were told these services would probably be covered in full by the Plan. The Plan denied your request. The Plan says these services were rendered by an OON provider, and the total liability amount of $72.00 was applied correctly. The Plan also says that the member liability is a contractual obligation under the Plan and cannot be waived.

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 the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 28, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the administration of the shingles vaccine (90471 and 90750) provided on September 21, 2020, through September 23, 2020.

You asked the Plan to pay for the administration of the shingles vaccine. You say that you would like reconsideration because you called the Plan and were told this vaccine would be covered. The Plan denied your request. The Plan says this is not a Medicare Part B covered service and cannot be paid under Medicare Part B.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the administration of the shingles vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the administration
of the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the administration of the shingles vaccine (90471 and 90750) provided on September 21, 2020, through September 23, 2020.

Benefits for the administration of the shingles vaccine 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 pay for the services provided to you by an out-of-network provider on February 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided to you by an out-of-network provider on February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 5, 2020, to August 14, 2020.

You asked the Plan to pay for the SNF services provided from August 5, 2020, to August 14, 2020. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee was discharged from skilled care as there was a lack of further progress.

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 the SNF services provided from August 5, 2020, to August 14, 2020. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient 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 the SNF services provided from August 5, 2020, to August 14, 2020 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 5, 2020, to August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to further pay for the emergency room services provided on October 6, 2020.

You asked the Plan to further pay for the services provided. You say that payment should be based on overall care. The Plan denied your request. The Plan says the documentation does not support the evaluation and management level as reported on the claim.

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 99285 is an emergency department visit with presenting problems of high severity and require urgent evaluation by the physician. We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee presented to the emergency department with dementia. The enrollee was in no acute pain. The records do not show that the enrollee presented with problems of high severity. 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 emergency room services provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Legacy Myeloid Molecular test rendered on February 15, 2021.

You asked the Plan to pay for these services. You say that you were not aware that the services wouldn't be covered. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that genetic sequencing panels are 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found you have low risk myelodysplastic syndrome (MDS) diagnosed with a bone marrow biopsy. A repeat biopsy was performed on February 24, 2020. You have worsening anemia. The criteria for coverage of the testing is not covered, as the testing is not necessary for MDS after initial diagnosis. The testing was not reasonable or medically necessary to impact the management or outcome of your treatment.

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 pay for the Legacy Myeloid Molecular test rendered on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88112 and 88305) provided to the enrollee on October 23, 2019, by an out-of-network provider.

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 this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 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 the laboratory services (CPT code(s): 88112 and 88305) provided to the enrollee on October 23, 2019, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor (CGM) supplies rendered from November 27, 2020 to March 3, 2021.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was 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 10% coinsurance for Medicare-covered durable medical equipment and related supplies. 

Review of the file shows that you received CGM supplies from November 27, 2020 to March 3, 2021. You have been asked to pay a 10% coinsurance for these services. These services fall within the Medicare-covered durable medical equipment and related supplies 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 continuous glucose monitor (CGM) supplies rendered from November 27, 2020 to March 3, 2021.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found you were admitted to the hospital with extra fluid around the heart (pericardial effusion). Your medical conditions are stable and you have no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do not require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 pre-approve the compression stockings.

You asked the Plan to pre-approve the compression stockings. You say that this request is medically necessary. The Plan denied your request. The Plan says the requirement for coverage has not been met.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code [enter HCPCS code] are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the compression stockings.