Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuing acute inpatient hospital care provided from August 30, 2021 forward.
You asked the Plan to pay for the continuing acute inpatient level of care. You say that the enrollee meets criteria for inpatient level of care. The Plan denied your request. The Plan says the enrollee appears to be stable for discharge and continued care could be given in alternate setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollee's condition can be managed safely only in the inpatient hospital setting.
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 continuing acute inpatient level of care. Our reviewer says that the inpatient services after August 30, 2021, are not medically necessary. Our physician reviewer found the inpatient services from August 30, 2021, forward will be considered not medically necessary. A lower level of care would have been more appropriate. 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 continuing acute inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pay for the continuing acute inpatient hospital care provided from August 30, 2021 forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for next generation sequencing testing provided on March 4, 2021.

You asked the Plan to pay for next generation sequencing testing. You say that this testing was ordered by the enrollee's treating physician to determine the best course of treatment. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the enrollee has previously been tested with the same test for the same cancer genetic content.

The Plan must follow Medicare rules. Medicare rules say that next generation sequencing testing may be covered under certain circumstances, including that the enrollee has not been previously tested with the same testing using NGS for the same cancer genetic content. 

We looked at the file and Medicare rules. The enrollee was previously tested with the same testing using NGS for the same cancer genetic content. Based on this information, we decided that Medicare rules for coverage of next generation sequencing testing have not been met. Therefore, we decided that the Plan does not have to pay for next generation sequencing testing provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic footwear rendered on April 28, 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.

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 pay for the orthopedic footwear rendered on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous (IV) Orencia.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has psoriasis and psoriatic arthropathy, congestive heart failure, and chronic obstructive pulmonary disease. He has not tried and failed the Plan's required drug, Stelara. The records do not support that the required drug would be contraindicated or less effective; therefore, Orencia is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve intravenous (IV) Orencia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230) provided on April 19, 2021.

You asked the Plan to pay for the intraoral x-rays. You say that you were not told at the time of service that these x-rays would not be covered. The Plan denied your request. The Plan says they have agreed to cover the bitewing x-rays; however, intraoral x-rays are not covered by your dental benefits at the time they were provided.

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 the intraoral x-rays (D0220, D0230) provided on April 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from January 3, 2021, to January 18, 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 claims were not billed correctly.

The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment.

We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 home health services rendered from January 3, 2021, to January 18, 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 records do not show the enrollee can do 3 or more hours per day of
skilled therapy at least 5 days a week.

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 anemia
secondary to gastrointestinal bleeding, COVID infection, stroke, and atrial fibrillation with rapid ventricular
response. 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: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve neuropsychological testing.

You asked the Plan to pre-approve neuropsychological testing. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 neuropsychological testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the American Academy of Neurology has concluded that neuropsychological testing is useful in identifying patients with dementia, particularly when administered to those at higher risk by virtue of memory impairment, such as this enrollee has. Follow-up testing can provide useful information of high diagnostic utility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have been met. Therefore, we decided that the Plan has to pre-approve neuropsychological testing.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic testing services and physician services provided on March 20, 2021.

You asked the Plan to waive the copayment for diagnostic testing services and physician services. You say that you should not have a copayment applied because this was an annual physical. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 copayment for outpatient diagnostic tests. 

The record shows the services provided by your physician went beyond the scope of an annual visit. Your contract with the Plan clearly says that you must pay a $10 copayment for primary care physician services. 

You have been asked to pay $35.81, which is less than the $50 copayment, for diagnostic testing services. Diagnostic testing services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $10 copayment for primary care physician services. Physician services fall within the physician/practitioner services, including doctor's office visits 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 diagnostic testing services and physician services provided on March 20, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for CPT code 99072.

You asked the Plan to pay for the services. The Plan says that the billed diagnosis code is inappropriate.

We decided that the Plan has to pay for CPT code 99211.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99211 is supported in the medical record. Specifically, the services in question were billed with diagnosis code Z20.828. The diagnosis code that the Plan is recommending, U07.1, would only be used if you had a confirmed case of coronavirus. The Plan has not provided any evidence or argument that showing that you had a confirmed case of coronavirus. Additionally, CPT 99211 is the correct code for an evaluation and management visit that resulted in a coronavirus test. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for CPT code 99211.

We also decided that the Plan does not have to pay for CPT code 99072.

The Plan follows Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the code 99072. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99072.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for MTHFR genetic testing provided on February 1, 2021.

You asked the Plan to pay for MTHFR genetic testing. You say that the enrollee clearly met the criteria for this testing. The Plan denied your request. The Plan says this testing is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is not covered by Medicare except in pregnant patients. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MTHFR genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for MTHFR genetic testing provided on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospital admission from September 2, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric hospital care. You say that you feel you are still a danger to yourself and others. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary because the records received show that your condition has improved, and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric hospital care. Our reviewer says that the continued inpatient psychiatric hospital care is not medically necessary. Our physician reviewer found that you did not require inpatient mental health treatment from September 2, 2021, forward as you were not a danger to yourself or others and do not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were not showing any aggressive behaviors being cooperative and compliant. 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 inpatient psychiatric hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric hospital admission from September 2, 2021, forward.
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 a non-participating provider.

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 rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 14, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set (S1015), infection
control supplies (S8301), additional supplies, materials, and clinical staff time (99072), and unlisted special
services (99199) provided during anesthesia services for a gastrointestinal procedure on February 10, 2021.

You asked the Plan to pay for the additional supplies, materials, and staff time related to anesthesia services.
You say that since you come to the provider's office you are able to bill for every single item and supply that
you bring with you and is used during anesthesia. The Plan denied your request. The Plan says these items are
coded incorrectly.

The Plan must follow Medicare rules. Medicare rules say that separate payment cannot be made for drugs,
supplies, and materials used in anesthesia care. Therefore, we decided that the Plan does not have to pay for the
intravenous (IV) tubing extension set (S1015), infection control supplies (S8301), additional supplies,
materials, and clinical staff time (99072), and unlisted special services (99199) provided during anesthesia
services for a gastrointestinal procedure on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on March 9, 2021.

You asked the Plan to pay for the Cxbladder Monitor test (0012M). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered. 

We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Myopro Motion G device (L8702).

You asked the Plan to pre-approve the Myopro Motion G device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is considered investigational and is not covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Myopro Motion G device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had a stroke in 2002 with a resultant left sided hemiparesis. The provided records do not document the failure of standard bracing and orthotic therapy. 

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 Myopro Motion G device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Myopro Motion G device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on April 5, 2021.
You asked the Plan to pay for the tooth extractions (D7210). You say that you have an outpatient surgery benefit at $200 a trip. The Plan denied your request. The Plan says the charges exceed your dental benefit maximum.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631, 87338) provided on August 10, 2020.

You asked the Plan to pay for laboratory services. You say that these are covered services. The Plan denied your request. The Plan says these services were billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631, 87338) provided on August 10, 2020.