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

We decided that the Plan does not have to waive the copayment for SNF care from July 12, 2019 through July
31, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
According to your 2019 EOC, when in-network, there is a $0 copayment for days 1-20; $100 copayment per
day for days 21-100, per benefit period. A benefit period begins on the first day you go to a Medicare-covered
inpatient hospital or a skilled nursing facility. The benefit period ends when you haven't been an inpatient at
any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended,
a new benefit period begins. There is no limit to the number of benefit periods you can have. Due to being
readmitted within 60 days of your previous Skilled Nursing Facility stay at the facility June 7, 2019-
through June 26, 2019, your stay July 12, 201 through July 31, 2019 is within the same benefit period.
Therefore, the claim processed correctly with a $100 copayment per day for days 21+ per EOC benefit. 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 SNF care from July 12, 2019 through July 31, 2019
provided by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT angiography of the heart (75574) provided on September 26, 2019.You asked the Plan to pay for the CT angiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate to submit multiple claims for the professional component (Modifier 26) of the same diagnostic test or radiologyprocedure, as this service is performed once by a single provider.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 CPT code75574 is not supported in the record. Specifically, the record does not include documentation to indicate why this service was provided twice and that it was medically necessary to provide it twice. Based on this information, we decided that Medicare rules for coverage of the CT angiography have not been met. Therefore, we decided that the Plan does not have to pay for a CT angiography of the heart (75574) provided on September 26, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on August 16, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 definitive drug testing rendered to enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services you received on July 9, 2019.You asked the Plan to waivethe copayment. You say that your copayment should be $0.The Plan denied your request. The Plan says you are responsible for the cost share.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 $150 copayment for each Medicare-covered visit to an outpatient hospital facility. Review of the file shows that you were provided outpatient hospital serviceson July 9, 2019. You have been asked to pay a $150 copayment for the services. The services fall within outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 waivethe copayment for the outpatient hospital services you received on July 9, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic sequencing DMA 342 genes test provided to the enrollee on May 25, 2018.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 none of the current submitted medical records supported the test for the date of service performed on 5/25/18 and these medical records are not applicable to this appeal.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 test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the documentation is insufficient to demonstrate that the coverage criteria for FoundationOne CDx genetic sequence testing were met in this case. It is not documented whether or not the enrollee had previously been tested using the same NGS test for the same primary diagnosis of cancer, or whether the enrollee decided to seek further cancer treatment (e.g., therapeutic chemotherapy).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 test have not been met.Therefore, we decided that the Plandoes not haveto pay forgenetic sequencing DMA 342 genes test provided to the enrollee on May 25, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for private duty aide services provided on August 19, 2019 through August 26, 2019.You asked the Plan to pay for the private duty aide services. You say that you need assistance with laundry, cooking, bathing, dressing, shopping and transportation. The Plan denied your request. The Plan says the services you are requesting are custodial care services and not covered under Medicare or your Plan.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the private duty aide services have not been met. The services you are requesting are considered custodial care and not covered by Medicare. Therefore, we decided that the Plan does not have to pay for private duty aide services provided on August 19, 2019 through August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care rendered to the enrollee on June 26, 2019.
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 99292 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 99292 is critical care, evaluation and management of the
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for
primary service).
We find that CPT code 99292 is not supported in the medical record. Specifically, the documentation shows
100 minutes of critical care time; therefore, the additional units for code 99292 are not supported. 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 critical care rendered to the enrollee on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 28, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says utilization of network providers when possible and
available and authorization are required.
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 has network providers
available who can provide 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 medical services provided on October 28, 2019
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 7, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 7, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX injections for the enrollee.You asked the Planto pre-approveSupartz FX. You say that  The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee in this case. The documentation does not support thatthe enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX injections for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on February 27, 2019.You asked the Plan to pay for train of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment of this service is bundled into other services.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 CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrical stimulation therapy (G0283) provided by the enrollee from July 22, 2019 to August 19, 2019.You asked the Plan to pay forthe electrical stimulation therapy.You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the services are not a covered benefit underMedicare oryour contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the servicesat issue arenot manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe electrical stimulation therapy (G0283) provided July 22, 2019 to August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on August 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plansays there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe laboratory services rendered on August 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on September 10, 2019.You asked the Plan to pay forthe ambulance service provided by the air ambulance crew.You say that the Plan should pay this claim.The Plan denied your request. The Plan says the flight was aborted and therefore the service will not be paid.ThePlan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service provided by the air ambulance crewhave not been met.The air flight was aborted before the enrollee was boarded. Therefore, we decided that the Plan does not have to pay forservices provided on September 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.You asked the Plan to pre-approveadditional mileage for routine transportationtrips. You say that the additional mileage is needed.The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 24 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of additional mileage for routine transportation trips have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 20, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to enrollee on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6241) and the 2 retainer crowns (D6751).You asked the Plan to pre-approve the dental services. You say that you were approved for the surgical removal of the tooth, but not for the bridge. You say that the area where your tooth was removed is currently bleeding and hurting. You say that you need ibuprofen 3 times per day to alleviate the pain.The Plan denied your request. The Plan says the requested services are not medically necessary.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. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested dental services do not meet the criteria for coverage. Our physician reviewer found coverage for a fixed bridge applies only to the replacement of a single maxillary anterior tooth or two mandibular anterior teeth. Tooth #13 is a posterior tooth. Therefore, the requested services do not meet the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve a pontic (D6241) and the 2 retainer crowns (D6751).
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 enrollee would benefit from IRF care as he requires intensive rehab and could tolerate up to three daily hours of therapy.The Plan denied your request. The Plan says the enrollee's medical condition does not require the oversight provided in the hospital setting. He is also not likely to be able to participate in three daily hours of therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 the member was admitted for acute care on 01/10/2020 after falling and sustaining multiple lower right rib fractures, a right hemothorax, and pneumothorax. He had SNF level care for 2 days beginning on 01/20/2020 and was readmitted with emesis. He had upper gastrointestinal bleeding as well as hyperkalemia, lactic acidosis, and acute kidney injury.The member's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. He is unable to perform essential activities such as bed mobility or transfer and requires an intensive rehabilitation therapy program. However, the member is limited by debility and the severity of his comorbid medical conditions with a limited upright positional tolerance. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block (64454).You asked the Plan to pre-approve the genicular nerve block. You say that this service is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says there is not enough evidence to show that this procedure is safe and that it works well for knee pain long term.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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of on-going clinical trials.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 genicular nerve block have not beenmet. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64454).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from February 25, 2018 to April 25, 2018.
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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must report one of the three Q codes (Q5001, Q5002, and Q5009). We looked at the file and Medicare rules. The claims were not billed with a required Q code. Therefore, we decided that the Plan does not have to pay for the home health services rendered to the enrollee from February 25, 2018 to April 25, 2018.