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

We decided that the Plan does not have to pay for the laboratory services provided on December 28, 2020.
You asked the Plan to pay for the laboratory services. 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 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 was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services provided on December 28, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on April 28, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received a CT scan on the date of service at issue in this appeal. The Plan says
that the correct copayment has applied per your contract with the Plan.

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 $150
copayment for each Medicare-covered advanced radiology service, such as CT scans.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a CT scan on
April 28, 2021. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the
Outpatient diagnostic tests 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 CT scan
provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve the requested services. You say that the enrollee needs the services due to pain. The Plan denied your request. The Plan says pain reduction following medial branch blocks is not quantified.

The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain medical indications.

We looked at the file and Medicare rules. The records provided do not show that the medial branch blocks provided a consistent minimum of 80% relief of pain. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met.

Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81407 and 81408) provided on January 15, 2021.

You asked the Plan to pay for the laboratory services. 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 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 was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81407 and 81408) provided on January 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the face joint injections, (64493, 64494, 64495). You say that the enrollee needs the injections for lower back pain relief. The Plan denied your request. The Plan says injections were requested for three levels and medical studies do not show this works better when done for more than two levels.
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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has had fusion at L2 to L4. The LCD specifically excludes levels of prior surgery. The request exceeds utilization criteria of 2 levels only. Only 2 levels are medically reasonable and 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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) (64495) have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device (22869).

You asked the Plan to pre-approve Vertiflex device. 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. 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 Vertiflex device. Our reviewer says that
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found the Vertiflex device is experimental, and more research is needed to show safety and efficacy of the
device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex device have not been met. Specifically, more research is needed to
show safety and efficacy of the device. This means the requested service is not medically necessary or
reasonable. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pneumatic compressor provided on April 19, 2021.
You asked the Plan to waive the coinsurance for the pneumatic compressor. You say this should be covered because your doctor prescribed it. You say that the coinsurance is very expensive. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for covered items and related supplies.
You have been asked to pay $999.40 which is 20% of the allowed amount for the pneumatic compressor. The allowed amount is $4,962. ($4,962 x 20% = $999.40). The pneumatic compressor falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the pneumatic compressor provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0266).

You asked the Plan to pre-approve a total electric hospital bed. You say that this request is medically necessary for the enrollee's current needs. The Plan denied your request. The Plan says this item is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0266).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess services represented by code 10061 provided on March 17, 2020.

You asked the Plan to pay for code 10061. You say that the medical records support the billing of code 10061. The Plan denied your request. The Plan says the medical records do not support the billing of code 10061.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 10061 is Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. 

We asked our coder 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 code 10061. Our reviewer says that the medical records do not support the billing of code 10061. Our reviewer found the record indicates that the enrollee underwent incision and drainage of a single simple lesion. The elements of the coverage determination are not satisfied. The requested service as billed cannot be recommended. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 10061 have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of abscess services represented by code 10061 provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and non-intravenous conscious sedation (D9248) provided on April 12, 2021 and April 19, 2021.

You asked the Plan to pay for dental codes D0150 and D9248. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the Plan paid for dental code D0150 from a previous visit you had on April 6, 2021. The Plan only covers this code once every three Plan years. The Plan said dental code D9248 is not a covered service under the Plan's supplemental dental 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D9248 is not among those covered under this benefit. Furthermore, the Plan contract clearly says that dental code D0150 is covered once every three Plan years. The file shows that the Plan previously paid for dental code D0150 from your visit on April 6, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and non-intravenous conscious sedation (D9248) provided on April 12, 2021 and April 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on April 1, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the laboratory services by a contract provider. The file does not show that the Plan
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the
laboratory services provided on April 1, 2021.
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: 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 requested admission to an IRF is not medically
necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
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.

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 office visit (99213) and the physician or allowed practitioner re-certification for Medicare-covered home health services (G0179) rendered by the out-of-network (OON) provider on March 3, 2021 and March 6, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 office visit (99213) and the physician or allowed practitioner re-certification for Medicare-covered home health services (G0179) rendered by the out-of-network (OON) provider on
March 3, 2021 and March 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in steady decline and the necessary respiratory services are not available at the local subacute facility The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on June 15, 2020.
You asked the Plan to pay for the laboratory services. 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.
We looked at the file and Medicare rules. The rules state that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen (81401, 81403, 81404, 81405, and 81406) was obtained in an office setting. The rules also explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The tests at issue in this appeal (81407 and 81408) were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided on June 15, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services rendered by a licensed counselor.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says that these services were not rendered by a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for services provided by a practitioner who is not a Medicare eligible provider. Your provided was a licensed counselor. This is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided from January 5, 2021, to April 27, 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.
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 requested admission to an IRF 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 do 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. 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.
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 the laboratory services provided on March 10, 2021.

You asked the Plan to pay for the laboratory services. 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 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 was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021.