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

We decided that the Plan has to pre-approve F1Heme testing provided on August 18, 2020.

You asked the Plan to pre-approve the F1Heme testing. You say that you would like reconsideration because the F1Heme test is a proven medically necessary covered benefit for comprehensive genomic profile (CGP) testing for cancer to identify potential targeted therapy option. The Plan denied your request. The Plan says that this service should be billed with CPT code 81479.

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 the F1Heme testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found molecular profiling/next generation sequencing (NGS) is considered a standard of care for determining any actionable mutation for which clinical trials or approved therapies are available. In hematological malignancies sometimes NGS can also aid with diagnosis. 

This member recurred 13 years after initial diagnosis 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 F1Heme testing have been met. Therefore, we decided that the Plan has to pre-approve F1Heme testing provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the medical records show medical necessity for the service rendered. The Plan denied your request. The Plan says services rendered by non-participating providers require 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 medical services provided on September 28, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular panel provided on June 1, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says a
cardiovascular risk assessment panel is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The testing at issue was requested for screening purposes. There are insufficient records to show that the
ordered testing is diagnostic, or clearly correlates any test result with given interventions. Medicare does not
cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the
cardiovascular panel provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the manual therapy techniques, application of a modality or electrical stimulation. You say that you are covered for manual manipulation. The Plan denied your request. The Plan says the remaining services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the manual therapy techniques, application of a modality or electrical stimulation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 80197, 82550, 83880, 85025, and 87497.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 the laboratory services are not supported in the medical record. Specifically, these services were billed with a place of service of 22 (outpatient). The billed services are considered global services and are not eligible for separate payment of the physician interpretation. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80053, 80197, 82550, 83880, 85025, and 87497.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on October 19, 2020.

You asked the Plan to pay for the hearing aids. You say that hearing aids from the network provider did not work. The Plan denied your request. The Plan says hearing services covered under the supplemental benefit must be obtained by a participating provider.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available to provide the items at issue in this appeal. The Plan did not pre-approve the services from the out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on October 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging, spinal canal and contents (72141).

You asked the Plan to pre-approve the MRI of the spinal canal and contents. You say that this service is medically necessary. The Plan denied your request. The Plan says the MRI is not considered medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI of the spinal canal and contents. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided medical records do not document any pain, muscle weakness, trauma, fever or concern for metastatic malignancy or other "red flags" that would necessitate an MRI. 

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 MRI of the spinal canal and contents have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging, spinal canal and contents (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available to provide 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 medical services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on June 3, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
include the time spent providing the critical care 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.
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate that
amount of time rendering the critical care services on the billed date of service. Based on this information, we
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided
that the Plan does not have to pay for critical care services (99291) provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the comprehensive periodontal evaluation (D0180) provided on October 27, 2020.

You asked the Plan to pay for the dental services. You say that you had some teeth that were causing you pain. You say that your gums were hurting as well. You also say that you went to see the dentist for a cleaning and were advised that you had gingivitis. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that comprehensive periodontal evaluation is not listed as a covered service.

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 frequency limit for the comprehensive oral evaluation has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on January 25, 2018. Additionally, the comprehensive periodontal evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the comprehensive periodontal evaluation (D0180) provided on October 27, 2020.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 the enrollee is currently undergoing treatment at an acute care hospital for aspiration and chronic renal failure. The enrollee is not intubated/ventilated. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pay for IRF care. You say that IRF care is necessary for the enrollee. The Plan denied your request. The Plan says IRF care 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 above. 

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 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require or to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete maxillary denture and complete mandibular denture provided by an OON provider.

You asked the Plan to pay more for the complete maxillary denture and complete mandibular denture. You say that the Plan never indicated OON to you during the several calls you made to them to check your benefits and costs. You also say that you were advised that the total cost would be covered by the Plan. The Plan denied your request. The Plan says this claim was paid up to the Allowed Maximum Charge for OON provider.

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, you are responsible for the difference between the billed amount and allowed amount. The record shows that the Plan contacted the provider and was advised that the provider wrote off $976 and is only billing you $228. Therefore, we decided that the Plan does not have to pay more for the complete maxillary denture and complete mandibular denture provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on June 2, 2020.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The cardiovascular risk assessment 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 cardiovascular risk assessment provided on June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require this on an intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 this service is medically necessary. The Plan denied your request. The Plan says the member has exhausted their inpatient days for this benefit period.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up 90 days per benefit period and 60 extra lifetime reserve days over your lifetime for inpatient days. 

We looked at the file and Medicare rules. The file shows that the enrollee has exhausted all of their days for this benefit period. Although the enrollee may still need inpatient care, the Plan is not required to pay for more than 90 days of inpatient coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided to the enrollee on April 26,
2020.
You asked the Plan to pay for the ambulance transport. You say that you would like payment for these services.
The Plan denied your request. The Plan says that they did not receive a primary carrier's Explanation of
Benefits.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the ambulance transport until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for the ambulance transport provided to the enrollee on April 26,
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on July 13, 2020.
You asked the Plan to pay for the assistant services. The Plan denied your request. The Plan says this procedure is not payable.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered.
In this case, you billed assistant surgery services for CPT code 45330. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient, new patient evaluation (99204) provided nor the outpatient visits (99214).

You asked the Plan to waive the copayments for the outpatient, new patient evaluation and the outpatient visits. You say that you would not have gone to the hospital had you known that you would be subject to outpatient fees. The Plan denied your request. The Plan says the claims were processed correctly.

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 $35 copayment for Outpatient hospital services.

You have been asked to pay a $35 copayment for the outpatient, new patient evaluation and the other outpatient visits. Each of these services fall within the Outpatient hospital 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 copayments for the outpatient, new patient evaluation (99204) provided nor the outpatient visits (99214).