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

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiogram (TTE)
you received on April 8, 2021.
You asked the Plan to waive the copayment for the TTE. You say that you were told this test would only cost
$20. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says
that their phone records clearly show that you called them prior to this service and you were told that this
service would have a $125 copayment, not a $20 copayment.
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 $125
copayment for diagnostic radiology services.
You have been asked to pay a $125 copayment for the TTE. The TTE falls within the diagnostic radiology
services 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 transthoracic
echocardiogram (TTE) you received on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) rendered by the out-of-network (OON) provider on February 15, 2021.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item was rendered by an out of network provider, without prior authorization.

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 item at issue in this appeal.

The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) rendered by the out-of-network (OON) provider on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the you dislocated your hip and fractured your foot. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cologuard testing rendered on March 3, 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 claim was not billed with the required diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing must be billed with ICD-10 diagnosis codes Z12.11 and Z12.12 or ICD-9 diagnosis codes V76.41 and V76.51. We looked at the file and Medicare rules. The file shows that the testing was not billed with the required diagnosis codes. 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 Cologuard testing rendered on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has no complex medical needs that require intensive rehabilitation.
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.
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 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 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is medically stable and does not have daily skilled nursing or therapy 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 the 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 the skilled nursing facility (SNF) care.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 surgical repair of ankle and olecranon fractures after a fall. 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, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81317, 81432, 81479) provided February 11,
2020.
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan
denied your request. The Plan says the genetic testing panel cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service providers should use
CPT code 81479.
We looked at the file and Medicare rules. Multiple unbundled CPT codes were billed for the same panel. Based
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.
Therefore, we decided that the Plan does not have to pay for genetic testing (81317, 81432, 81479) provided
February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular genetic screening testing provided on August 10, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this testing is not covered for screening purposes.
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. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular genetic screening testing provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01402 and the injection 
services coded 64447 provided on October 14, 2020. 
 
You asked the Plan to pay for the anesthesia services and the injection services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not 
support the services billed. 
 
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 codes 01402 and 64447 are not supported in the medical record. Specifically, the 
documentation submitted did not include an anesthesia record for open or surgical arthroscopic procedures on 
knee joint; total knee arthroplasty; therefore, code 01402 cannot be verified. The documentation does not 
support the comprehensive procedure code of 01402; therefore, code 64447 cannot be verified. Based on this We decided that the Plan does not have to pay for the anesthesia services coded 01402 and the injection 
services coded 64447 provided on October 14, 2020. 
 
You asked the Plan to pay for the anesthesia services and the injection services. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not 
support the services billed. 
 
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 codes 01402 and 64447 are not supported in the medical record. Specifically, the 
documentation submitted did not include an anesthesia record for open or surgical arthroscopic procedures on 
knee joint; total knee arthroplasty; therefore, code 01402 cannot be verified. The documentation does not 
support the comprehensive procedure code of 01402; therefore, code 64447 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the anesthesia services and the injection services 
have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 
01402 and the injection services coded 64447 provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 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 March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid coded 87798 and 87801 provided on February 8, 2021.
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 codes 87798 and 87801 are not supported in the medical record. Specifically, the documentation shows that the enrollee received a urinary tract infection panel including antibiotic resistance markers utilizing polymerase chain reaction (PCR) testing of the urine. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The documentation does not include documentation as to why the PCR testing would have been more beneficial for the enrollee. The Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid coded 87798 and 87801 provided on February 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services as of 08/21/2021. The enrollee does require skilled therapy services. Based on the medical records provided daily skilled services are not required as of 08/21/2021 due to the enrollee's lack of progress with therapy. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid batteries provided on January 15, 2021.

You asked the Plan to pay for the hearing aid batteries. You say that that your hearing aid batteries should be covered under the pick your perks program. The Plan denied your request. The Plan says hearing aid batteries are not an eligible expense for Pick Your Perks.

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.

We looked at the file and the Plan's rules. The file shows that hearing aid batteries are not a Plan covered hearing benefit. Therefore, we decided that the Plan does not have to pay for hearing aid batteries provided on January 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the continuation of SNF care 
from August 14, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for continued SNF care from August 14, 2021 and forward. We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the continuation of SNF care 
from August 14, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for continued SNF care from August 14, 2021 and forward.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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with 
pneumonia and chronic obstructive pulmonary disease. From a nursing perspective, the enrollee received oral 
and inhaled medications.  The enrollee had stable vital signs. He used oxygen via nasal cannula. Regarding 
rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the 
dates in question, the enrollee was at a minimal to maximal assist level with bed mobility and transfers. He was 
dependent for ambulation. The enrollee required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half
leg (E0673) provided December 27, 2020.
You asked the Plan to pay for the pneumatic appliance. You say that please find the medical records attached
for the claim to be processed. The Plan denied your request. The Plan says pneumatic compression device is
not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
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 enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) provided December 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0031U, 81479, 81225, 81226, 81230, 81231,
81328) provided August 25, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed 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 codes 0031U, 81479, 81225, 81226, 81230, 81231 and 81328 are not supported in the
medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place
of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for
lab services (0031U, 81479, 81225, 81226, 81230, 81231, 81328) provided August 25, 2020.