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

We decided that the Plan does not have to pay for a comprehensive pharmacogenetic panel (81240, 81225, 81227, 81226, 81241, 81328, 81355, 81401, 81479, 81335, 81230, 81231, 81291) provided on February 4, 2021.

You asked the Plan to pay for a comprehensive pharmacogenetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. 

We find that CPT codes 81240, 81225, 81227, 81226, 81241, 81328, 81355, 81401, 81479, 81335, 81230, 81231, and 81291 are not supported in the medical record. Specifically, the record shows that these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a comprehensive pharmacogenetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive pharmacogenetic panel (81240, 81225, 81227, 81226, 81241, 81328, 81355, 81401, 81479, 81335, 81230, 81231, 81291) provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the excision of a benign lesion provided on December 21, 2020.

You asked the Plan to waive the copayment for the excision of a benign lesion. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received the excision of a benign lesion on December 21, 2020, at an outpatient hospital facility. The excision of a benign lesion is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment.

You have been asked to pay a $150 copayment for the excision of a benign lesion. The excision of a benign lesion falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 excision of a benign lesion provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 16, 2021.

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 services are not covered.

The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities. 

We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. 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 laboratory services rendered on February 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colpopexy provided on March 2, 2021.

You asked the Plan to waive the copayment for a colpopexy. You say that you feel that you are being balanced billed. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received a colpopexy at an outpatient hospital facility on March 2, 2021. A colpopexy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $290 copayment. 

You have been asked to pay a $290 copayment for a colpopexy. A colpopexy falls within the outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colpopexy provided on March 2, 2021.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH 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. Specifically, medically necessary services are being obtained at the enrollee's current level of care and they do not require any additional
services. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of mini-implant (D6013) and modification of removable prosthesis following implant surgery (D5875).

You asked the Plan to pre-approve the mini-implant and modification of removable prosthesis. You say that you need these services to support your necessary dentures. The Plan denied your request. The Plan says these services are not covered under you 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 pre-approve surgical placement of mini-implant (D6013) and modification of removable prosthesis following implant surgery (D5875).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Onpattro.

You asked the Plan to pre-approve Onpattro. You say that the enrollee does not have "wild type". You say that the enrollee has polyneuropathy of hereditary transthyretin mediated amyloidosis of adults. You also say that Onpattro is indicated for the requested use. The Plan denied your request. The Plan says that the request does not meet Food and Drug Administration (FDA) approved labeling criteria.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Onpattro. Our reviewer says that the requested drug, Onpattro, is medically necessary. Our physician reviewer found the requested drug, Onpattro, is FDA approved for use in polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults. The reviewer found that the enrolle otherwise has no contraindications to the use of the requested drug. The reviewer also found that the requested dosing is otherwise consistent with the FDA approved labeling. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onpattro have been met. Specifically, the file shows that the requested use of Onpattro is FDA approved for the enrollee's diagnosis. Therefore, we decided that the Plan has to pre-approve Onpattro.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on February 8, 2021.
You asked the Plan to pay for the hearing aids. You say that you confirmed a change in benefit structure in
2021 that you could buy the new aids from the established ENT and audiologist. You say that it is the same
payout no matter which vendor is used, and the claim should be approved. The Plan denied your request. The
Plan says the hearing aids were received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for two
hearing aids a year only when they are received from a contracted vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids provided on February 8, 2021.
Your complaint about being unfair and coercive is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
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 based on the records there are no complex nursing or rehabilitation needs. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on November 17, 2019.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not include a critical care note for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on November 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471).

You asked the Plan to pre-approve the dental service. You say that you need this service so that your new dentures to fit properly. You say that you have not had teeth since 2009. You also say that you have not been able to chew your food properly. The Plan denied your request. The Plan says removal of lateral exostosis is not listed as a covered service.

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 removal of lateral exostosis is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader and sensor.

You asked the Plan to pre-approve a Freestyle Libre 14 day reader and sensor. You say that you saw on the television that you could get these items for free. The Plan denied your request. The Plan says you do not meet criteria for the requested items.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day reader and sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader and sensor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility services you received from January 11, 2021, to January 31, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you had to stay extra time in the nursing home because you couldn't be released without a prescription for oxygen. You had to stay extra days awaiting this prescription. The Plan denied your request. The Plan says you were charged this copayment 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 $0 copayment for days 1-20, and a $184 copayment for days 21-100 for skilled nursing facility services.
Records show that in the month of January, you were in the nursing facility for a total of 21 days. You have been asked to pay a $0 copayment for days 1-20, and a $184 copayment for the 21st day for the skilled nursing facility services. This copayment applies regardless of the reason for the length of the stay. 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 skilled nursing facility services you received from January 11, 2021, to January 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient or outpatient dialysis services (90999) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve dialysis services. You say that you have been going to this dialysis for 2 years. When you started with this provider you were not enrolled in the Plan. The Plan denied your request. The Plan says you were approved for 24 visits (8 weeks) in order to transition to an in-network facility to meet your ongoing dialysis needs. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent 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 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 inpatient or outpatient dialysis services (90999) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic radiology simulation-aided field setting coded 77290 provided on March 31, 2021.

You asked the Plan to pay for the therapeutic radiology simulation-aided field setting. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not payable.

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 77290 is therapeutic radiology simulation-aided field setting; complex.

We find that CPT code 77290 is not supported in the medical record. Specifically, this service was billed within 90 days of billing code 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications). This means that code 77290 is bundled into the payment for 77301. Based on this information, we decided that Medicare rules for coverage of the therapeutic radiology simulation-aided field setting have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic radiology simulation-aided field setting coded 77290 provided on March 31, 2021.