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

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on September 6, 2020.
You asked the Plan to pay for Guardant360 testing. You say that this is a Medicare-covered service. 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. CPT code 81479 is used to bill for Guardant360 testing.
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported in the medical record. Specifically, these codes were used to report Guardant360, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 81301, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on September 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for the ambulance transportation (A0428, A0425) received March 1, 2021.

You asked the Plan waive the copayment for the ambulance transportation. You say that you did not call the ambulance for transfer to another hospital. The Plan denied your request. The Plan says the correct cost share applied to the claim

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 $250 copayment for Ambulance Services. 

You have been asked to pay a $227 copayment for the ambulance transportation. This amount is less than the required copayment of $250 for Ambulance Services. 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 waive the copayment for the ambulance transportation (A0428, A0425) received March 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued SNF stay.

You asked the Plan to pre-approve the continued SNF stay. You say that you feel that you still need the SNF benefits. You also say that you are still feeling quite weak, still need the SNF benefits, and do not want to be alone at this time. The Plan denied your request. The Plan says based on the documentation provided it does not appear that the coverage criteria are met for a continued SNF stay from July 6, 2021 forward.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued SNF stay. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued SNF stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Econazole Nitrate 1% cream.
You asked the Plan to pre-approve Econazole Nitrate 1% cream. You say that the enrollee has tried and failed multiple other medications. The Plan denied your request. The Plan says the requested drug is self-administered and is not covered under your contract.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Econazole Nitrate 1% cream.
Benefits for Econazole Nitrate 1% cream may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 15, 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.
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 test at issue in this appeal, a cardiovascular risk assessment panel, 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 rendered on January 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 31, 2020.
You asked the Plan to pay for the ambulance response. You say that you called 911 and they sent the fire department. The Plan denied your request. The Plan says without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. This requirement is waived in cases where an individual would have been transported to a covered destination, but such transport did not occur as a result of community-wide emergency medical service (EMS) protocols in place due to the COVID public health emergency. The beneficiary's condition must have required both the ambulance transportation itself and the level of service provided in order for the billed service to be considered 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 pay for the ambulance response and treatment. Our physician reviewer found the documentation does not support that ambulance transport was not provided due to EMS protocol. On the contrary, EMS advised transport and the patient refused. We looked at this physician's review, the file, and Medicare rules. The ambulance company did not provide transport services on December 31, 2020. The ambulance benefit is a transportation benefit. In this case we did not find that the ambulance was not provided due to EMS protocol in place due to the COVID public health emergency. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that you need to be in the hospital for two nights after surgery. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation that you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a planned vaginal hysterectomy and colporrhaphy. You are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT codes for vaginal hysterectomy and colporrhaphy are not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided December 15, 2020.

You asked the Plan to pay for the orthoses. You say that the claim was denied for multiple reasons. These records proved the necessity for medical treatment and wearing knee braces. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen supplies rendered on December 21, 2020 to January 21, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was applied 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 a 10% coinsurance for all other Medicare-covered durable medical equipment.
Review of the file shows that you received oxygen supplies on December 21, 2020 to January 21, 2021. You have been asked to pay a 10% coinsurance for these services. These services fall within the all other Medicare-covered durable medical equipment 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 oxygen supplies rendered on December 21, 2020 to January 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide unlimited routine transportation trips.
You asked the Plan to provide additional transportation. You say that this transportation is necessary for this enrollee to get to their dialysis appointments. The Plan denied your request. The Plan says up to 60 routine transportation trips are covered per year. Additional trips are not covered by this benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the request for unlimited trips exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide unlimited routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health and addiction residential services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON mental health and addiction residential services. You say that this is medically necessary. The Plan denied your request. The Plan says it is not necessary for the enrollee to use an out-of-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 OON mental health and addiction residential services. Our reviewer says that the requirements for coverage of services with the requested provider have not been met. Our physician
reviewer found the enrollee is not a danger to himself or others and is cooperative and compliant. It does not appear medically necessary and reasonable to have psychiatric and detoxification care provided at the requested out-of-network acute inpatient 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 OON mental health and addiction residential services have not been met. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON mental health and addiction residential services. Therefore, we decided that the Plan does not have to pre-approve mental health and addiction residential services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on September 21, 2020.
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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 supplies rendered on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 4, 2021 to February 8, 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 procedure code 99291 is not supported.
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 medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care services for the dates of service at issue. 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 critical care services rendered on February 4, 2021 to February 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 SNF care. 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. This
patient does not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a
qualified therapist are not required to safely and effectively provide medically necessary and reasonable
treatment. Daily skilled services are not required. This patient does not require the services on an inpatient
basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
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 SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found in this case you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care 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 pre-approve BRCA gene analysis services.
You asked the Plan to pre-approve BRCA gene analysis services. You say that this test is very important to the health of your family. You say that you want to live a long life and need to have this knowledge so you can plan accordingly. The Plan denied your request. The Plan says the requested genetic testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is excluded from coverage for individuals with no personal history of cancer. 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 BRCA gene analysis services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee's daughter recently tested positive for the BRCA1 gene. The enrollee states that her paternal grandmother died of breast cancer, and that two of her aunts have breast cancer. The documentation does not support that the enrollee in this case has a personal history of cancer, such as breast, ovarian, or pancreatic cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BRCA gene analysis services have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA gene analysis services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 25, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that this was the first visit as a new patient with this provider and a comprehensive oral evaluation was required. The Plan denied your request. The Plan says the requested service is limited to one procedure every three years.
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 only covered under this benefit once every three years. The Plan last covered a comprehensive oral evaluation on January 13, 2020. When you received this service on February 25, 2021 your benefit was exhausted. Therefore,
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received February 25, 2021.