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

We decided that the Plan does not have to pay for the evaluation and management services provided on February 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the doctor provided services in good faith. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers and authorization for certain 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The file shows that the enrollee was seen for a workup for breast cancer management. The 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 evaluation and management services provided on February 24, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for implant related services (D6052 x4) provided on January 5, 2021.
You asked the Plan to pay for implant related services. You say that you disagree with the denial of the services. The Plan denied your request. The Plan says the services at issue are not covered 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 pay for implant related services (D6052 x4) provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 8, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362 and L36523 to support their denial. However, LCD L36139, L36129, L36362 and L36523 are not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36139, L36129, L36362 and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 14, 2021 by an out-of-network (OON) provider. You asked the Plan to pay for the office visit. You say that the enrollee was seen for a visit to reestablish care for diabetes and chronic back and neck pain. You say you would like this claim authorized and reprocessed. The Plan denied your request. The Plan says no prior authorization was 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 an office visit provided on April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the manual manipulation of the spine (98940) or pay for the office visit (99203) provided on April 13, 2021.
You asked the Plan to waive the copayment for the manual manipulation of the spine and pay for the office visit. You say that you would like reconsideration because these services should be covered by the Plan. The Plan denied your request. The Plan says in network, you are responsible for a $10.00 copayment for each visit to see a chiropractor and the initial office visit is not a covered service under your plan when services are rendered by a chiropractor provider.
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 rules also say that in-network, you are responsible for a $10 copayment for each chiropractic visit. We looked at the file and rules. Based on this information we decided that coverage criteria have not been met. Specifically, the initial office visit is not a covered benefit as the Plan only pays for manual manipulation of the spine. Additionally, you have been asked to pay a $10 copayment for the chiropractic services. This is the appropriate copayment per your contract with the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the manual manipulation of the spine (98940) or pay for the office visit (99203) provided on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty lower eyelids (15821).
You asked the Plan to pre-approve blepharoplasty lower eyelids. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that eyelid surgeries may be considered reconstructive in nature for the indications listed in the Medicare Rules section where there is functional impairment as documented by preoperative frontal and lateral photographs. 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 blepharoplasty lower eyelids. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation of functional visual impairment, and there is no supporting documentation with frontal and lateral photographs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of blepharoplasty lower eyelids have not been met. Specifically, there are no frontal and lateral photographs to support any of the indications for reconstructive surgery. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty lower eyelids (15821).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9367) provided from January 15, 2021, to January 21, 2021.
You asked the Plan to pay for the home infusion therapy. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9367 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9367) provided from January 15, 2021, to January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crown (code D2740), bone replacement graft (D7953), application of autologous blood concentrate product (D7921), cone beam computed tomography (D0365), fixed partial denture sectioning (D9120), radio/surgical implant index (D6190), and free soft tissue graft procedures (D4277 and D4278).
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 dental crown (code D2740), bone replacement graft (D7953), application of autologous blood concentrate product (D7921), cone beam computed tomography (D0365), fixed partial denture sectioning (D9120), radio/surgical implant index (D6190), and free soft tissue graft procedures (D4277 and D4278).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are medically stable and have no skilled nursing needs. Functionally, you do not require daily skilled therapy services on an inpatient basis in an SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on December 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on December 2, 2020.
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 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 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. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pay for the wound care services provided on March 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were provided prior to obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says authorization is missing.
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 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 wound care services provided on March 24, 2021 by an out-of-network (OON) provider.
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 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 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 ofyour 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. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that a delay in an IRF stay will jeopardize the enrollee's chance for a full recovery. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 that 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. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on February 11, 2021.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the enrollee has active coverage for this service. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a Doctor of Psychology is not eligible to enroll in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychiatric diagnostic evaluation has not been met. The record shows this provider is a Doctor of Psychology (Psy-D). Psy-Ds are not eligible to enroll in Medicare, therefore this provider is not payable Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a diagnostic evaluation (D9310), and endodontic therapy premolar tooth excluding the final restoration (D3320) provided on March 8, 2021.
You asked the Plan to reimburse you an additional amount for a diagnostic evaluation, and endodontic therapy premolar tooth excluding the final restoration. You say that you were told that the services were coded incorrectly. The Plan denied your request. The Plan says the cost share for the endodontic therapy premolar tooth excluding the final restoration was applied correctly. A diagnostic evaluation is not a covered benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Plan rules. Based on this information, we decided that the Plan's rules for coverage of a diagnostic evaluation, and endodontic therapy premolar tooth excluding the final restoration have not been met. Specifically, you have been asked to pay a $173.10 coinsurance and deductible for the endodontic therapy premolar excluding the final restoration. ($296.20 x .50 = $123.10 + $50 = $173.10). Additionally, the diagnostic evaluation (D9310) is not listed as a covered benefit in your contract with the Plan. The record indicates that you have been reimbursed the correct amount by the Plan. Therefore, we decided that the Plan does not have to reimburse you an additional amount for a diagnostic evaluation (D9310), and endodontic therapy premolar tooth excluding the final restoration (D3320) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing services provided on December 22, 2020.
You asked the Plan to pay for the definitive drug testing. You say that the testing was medically necessary and should be paid. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The file does not support that the sample was taken directly by the laboratory. As such, POS code 81 is not appropriate. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing services provided on December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 1, 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 were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 1, 2021.