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

We decided that the Plan does not have to waive the copayment forthe CT scan provided .You asked the Plan to waive the copayment forthe CT scan. You say that you received a bill for a service provided over a year ago. You say that you have never paid a copayment for authorized x-rays.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 radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment forthe CT scan provided .
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided .

You asked the Plan to pay for the emergency department visit. 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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

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 emergency department visit. Our reviewer says that the services billed are not supported by the documentation. Our physician reviewer found the medical records provided do not include sufficient documentation to meet the criteria for billing CPT 99285 as described in the code definition, therefore, this service cannot be verified.

We note that the plan has paid this claim at the CPT code of 99284. 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 emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided .
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen with
and without contrast (74170).

You asked the Plan to pre-approve this service. You say that a CT scan of the abdomen is medically necessary
for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 this service. Our reviewer says that a
CT scan of the abdomen is not medically necessary. Our physician reviewer found the records show that the
enrollee may have a lesion in the kidney(s). A lesion is a region in an organ or tissue that has suffered damage
through trauma or disease. The reason the request cannot be approved is because there is an approval code for
the same study, or a similar study, that is on file in the enrollee's records. This approval is still in effect. The
clinical information submitted does not describe results of this prior imaging, or if there are plans to use this
approval. The approved study may be sufficient for the evaluation of the enrollee's current clinical condition.
Guidelines do not support additional imaging without knowing the outcome of the prior approval.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography (CT) scan of the abdomen with and without contrast (74170).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forovarian oncology testing provided to you.You asked the Plan to pay forthe testing. The Plandenied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that the multimarker serum tests addressed in the applicable LCD are non-covered at this point in time. We looked at the file and Medicare rules. Per LCD L38371, the requested testing is non-covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forovarian oncology testing provided to you
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you feel the enrollee meets Medicare criteria for
Acute Inpatient Rehab. The Plan denied your request. The Plan says this request is 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. Our physician reviewer also
found that there is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing (81408, 81479) provided.You asked the Plan to pay forgenetic testing. 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 two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel.We find that CPT codes 81408 and 81479 are not supported in the medical record. Specifically, the services performed are considered to be a panel and should be billed with a single code.Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forgenetic testing (81408, 81479) provided
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy with an out-of-network provider.

You asked the Plan to pre-approve psychotherapy. You say that the enrollee has tried several other therapists and they were not a good fit. You say that an in-network provider is not able to provide the proper approaches. The Plan denied your request. The Plan says care must be received by a network provider.

The Plan must follow Medicare rules. Medicare rules say that Mental Health Counselor (MHC or LMHC) are not eligible providers with Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.

You asked the Plan to pre-approve Humira. You say that Humira is warranted as appropriate and medically necessary for the enrollee. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.

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 Humira.

Benefits for Humira 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a sanitation fee (D1999) provided with dental services.

You asked the Plan to pay for a sanitation fee. You say that you don't understand the amount you are being billed. The Plan denied your request. The Plan says this $10 sanitation charge is not covered. Please note that the Plan has indicated that they have reached out to the provider and have confirmed that you will no longer be balance billed for other 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 a sanitation fee (D1999) provided with dental services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke with right sided weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupationaltherapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.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 Plandoes not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services received .You asked the Plan to pay forthe dental services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthedental services received
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Medicare criteria for continued skilled nursing facility level of coverage were not met.

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 skilled nursing services. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare could be received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonableand 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure, third degree heart block, acute respiratory failure, and aortic stenosis Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the IRF admission approved.The Plan denied your request. The Plan says this request is 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 requestto 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. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 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-approveacute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordiabetic shoes (A5501, A5513) provided .You asked the Plan to pay forthe diabetic shoes. You say that the items were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order. The physician order provided is dated November 19, 2020. This is after the dates of service on the claim. Additionally, no itemized shipping documentation was provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fordiabetic shoes (A5501, A5513) provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora CGM supply allowance (K0553) provided .You asked the Plan to pay fora CGM supply allowance. You say that the items are medically necessary.The Plan denied your request. The Plan says there is insufficient documentation for this request.The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a CGM supply allowance. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation provided indicating that the beneficiary uses a DME receiver for a therapeutic CGM.
We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of a CGM supply allowance have not been met. Specifically, there is no documentation indicating the use of a CGM. This means the CGM supply allowance is not medically necessary or reasonable.Therefore, we decided that the Plan does not have to pay fora CGM supply allowance (K0553) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora routine physical examination provided You asked the Plan to pay forroutine physical exam. You say that you feel this claim should be paid by the Plan because it all revolved around an error by the Plan's house call nurse.The Plan denied your request. The Plan says the denial of payment for this service is correct, because an annual routine physical exam is covered once per year and you previously received an annual routine physical exam .The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover a comprehensive preventive medicine evaluation (routine physical). However, the Plan includes a benefit that covers one annual routine physical exam per year.We looked at the file and Medicare rules. You previously received an annual routine physical exam . Based on this information, we decided that the Plan's rules for coverage of routine physical exam have not been met.Therefore, we decided that the Plan does not have to pay fora routine physical examination provided.