Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) for antibiotic treatment provided from February 29, 2020, through March 5, 2020 billed with code S9500.
You asked the Plan to pay for the HIT services. You say that this was medically necessary and should be paid. The Plan denied your request. The Plan says this was billed with an invalid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
CPT code S9500 has a status indicator of "I" in the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) for antibiotic treatment provided from February 29, 2020, through March 5, 2020 billed with code S9500.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genomic sequence analysis panel (81455) provided on July 30, 2020.
You asked the Plan to pay for a genomic sequence analysis panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary.
We looked at the file and Medicare rules. The testing at issue is unlikely to impact therapeutic decision-making in the clinical management. Based on this information, we decided that Medicare rules for coverage of a genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for a genomic sequence analysis panel (81455) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 12,
2021.

You asked the Plan to pay for a telehealth office visit. You say that this was billed correctly. The Plan denied
your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services
claims, using Place of Service (POS) 02-Telehealth, to indicate the billed service was furnished as a
professional telehealth service from a distant site.

We looked at the file and Medicare rules. The record indicates that the service at issue was a telehealth service, but it was reported with POS 12 instead of 02. Based on this information, we decided that Medicare rules for coverage of a telehealth office visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth office visit (99214) provided on January 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is medically necessary. The Plan denied your request. The Plan says criteria for SNF care are 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 pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had a recent left total knee replacement and a gastrointestinal bleed. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was treated for acute blood loss anemia. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the acute hospital. The beneficiary was at a contact guard assist level with functional mobility including gait to 125 feet x 2 with a rolling walker. 

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily skilled therapy services. This beneficiary 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on January 13, 2021.

You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-covered. 

We looked at the file and Medicare rules. The testing at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81401) provided on July 27, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was provided in good faith. 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 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, and 81401 are not supported in the medical record. Specifically, the record shows that genes were assayed in parallel and should be reported 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 for genetic testing (81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81401) provided on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says gradient compression stockings described
by code A6530 are non-covered under Medicare and the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. You say that the enrollee currently resides in an assisted living facility that does not provide all of the therapies needed. The Plan denied your request. The Plan says SNF care 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for a UTI. The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a supervision to contact guard assist level with functional mobility, including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee worked with speech therapy on expressive aphasia. There are no identifiable skilled nursing needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body (CPT code 78816) provided to the enrollee on November 6, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; whole body (CPT code 78816) provided to the enrollee on November 6, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tempus xT gene panel (81206, 81272, 81235, 81210)
provided on May 11, 2020.
You asked the Plan to pay for a Tempus xT gene panel. You say that this was medically necessary. The Plan
denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests using Next Generation
Sequencing (NGS) must have FDA-approval or clearance.
We looked at the file and Medicare rules. The record shows that the testing at issue does not have FDAapproval
or clearance. Based on this information, we decided that Medicare rules for coverage of a Tempus xT
gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus xT gene
panel (81206, 81272, 81235, 81210) provided on May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with power options.

You asked the Plan to pre-approve the power wheelchair (PWC). You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.

The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. 

We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment in November of 2016. This PWC is still within the 5-year RUL and the documentation submitted does not show that the PWC is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the PWC at issue. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with power options.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.

You asked the Plan to pre-approve a skilled nursing facility admission. You say that the ernrollee was evaluated by physical therapy and recommended to continue skilled physical therapy in a SNF. The Plan denied your request. The Plan says the services requires can safely be received at a different setting.

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 a skilled nursing facility admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided this patient does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided there is no documentation that daily skilled services are required. Based on the medical records provided this patient 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 a skilled nursing facility admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Medicare guidance says the expandable controller, harness, and the electrical connection between the wheelchair controller and two or more motors are denied as there is not a medical need to control the requested power options through the joystick. The control of the power options on the wheelchair comes with their own switches. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT code 64624) provided on January 14, 2021, by the outpatient department of the hospital.

You asked the Plan to waive the copayment for the services. You say that you were quoted a $60 copayment. You state this was not a surgery. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file show that you received destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT code 64624) on January 14, 2021, by the outpatient department of the hospital. You were asked to pay a $300 copayment for the services. Your 2021 EOC states, "enrollees must pay a $300 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 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 destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT code 64624) provided on January 14, 2021, by the outpatient department of the hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received February 4, 2021.

You asked the Plan to pay for the extraction. You say that you have a limited income, and you would like the Plan to pay for the extraction. The Plan denied your request. The Plan says extractions are limited to two per year.

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. The Plan covers the extraction when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. The Plan has submitted evidence that claims for two extractions were paid out, exhausting your calendar year benefit. Based on this information, we decided that the Plan's rules for coverage of the extraction have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) received February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an out-of-network office visit provided on February 25, 2021.
You asked the Plan to waive the coinsurance for an out-of-network office visit. You say that you should have been billed for a wellness office visit. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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% coinsurance for a PCP office visit with an out-of-network provider.
The allowed amount of the claim is $124.32, resulting in a coinsurance obligation of $62.16. The EOC confirms that you pay a 50% coinsurance for an out-of-network PCP office visit. The records show you had your office visit with an out-of-network provider. 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 coinsurance for an out-of-network office visit (99214) provided on February 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the continuation of SNF care. You say that the clinical documentation provided supports the medical need for a continuation of SNF care. The Plan denied your request. The Plan says the enrollee's only daily skilled need is IV antibiotics, which can be provided at home with home infusion services. The Plan says that the enrollee can also arrange home physical therapy.

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 medical records provided show that the enrollee does require skilled nursing services and skilled therapy services. The skilled nursing services are required on a daily basis for the administration of the Ceftriaxone. However, the medical records provided do not show that the enrollee requires the needed services on an inpatient basis, only in a SNF setting. Our physician reviewer found that services in the home, in an assisted living facility with home health services, or in a long-term care facility on a part-time basis appear to be appropriate in this case. 

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 a continuation of skilled nursing facility (SNF) services.