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

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on January 22,
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 were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing is covered when specific criteria are met. 

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has unspecified anxiety disorder and single episode major depressive disorder, mild. The progress note dated January 22, 2021 states that Celexa and Cymbalta have been trialed but the enrollee did not feel any effects from the medications. The clinical record does not clearly show the use of or intent to prescribe a drug that has known drug-gene interactions that require a PGx test to be ordered to define the safe use of that drug in that patient. The testing was not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided December 7, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.

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 G0483 is Drug Testing, 22 or more drug classes.

We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not support
that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab
services (G0483) provided December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revision of shoulder joint replacement surgery.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this surgery is helpful for the treatment of the health problem.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has previously had a shoulder arthroplasty. The enrollee has persistent pain. The medical records indicate that the physician believes that the enrollee has impingement syndrome. Imaging demonstrates well seated arthroplasty without concern for loosening or infection. The provided medical records do not establish the medical reasonableness or necessity of the requested service as defined by Medicare rules.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve revision of shoulder joint replacement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on September 14, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on
September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 documentation does not support that you in require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for you. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time. 

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on January 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not
covered.

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 chiropractic services provided on January 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the yoga class donation.

You asked the Plan to pay for the yoga class donation. You say that you would like reimbursement for the yoga
class donations. The Plan denied your request. The Plan says there is no coverage for yoga class donations.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $150
towards gym memberships.

The Plan's rules for coverage of gym benefits have not been met because the Plan contract does not include
benefits for yoga class donations. Therefore, we decided that the Plan does not have to pay for the yoga class
donation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on September 8, 2020.

You asked the Plan to pay for the definitive drug testing. You say that the records support the need for this
testing. The Plan denied your request. The Plan says this was not billed with an appropriate POS code.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly.

We looked at the file and Medicare rules. The documentation does not support that this sample was taken by
the laboratory directly, meaning that POS code 81, as reported, is not supported. Based on this information, we
decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we
decided that the Plan does not have to pay for the definitive drug testing provided on September 8, 2020.
Appeal type: Home Health
Decision: Partially Favorable

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our reviewer
says that the nursing visits are medically necessary and the physical therapy visits are not medically necessary.
Our physician reviewer found the records show that you require wound care for open wounds on your foot.
These wounds can be difficult to reach, and your spouse is not able to assist in your care. Monitoring by skilled
nursing is therefore reasonable and medically necessary for wound care.
You are able to ambulate with supervision and do not need home health physical therapy at this time. The
physical therapy visits are not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing visits have been met. Therefore, we decided that the Plan has
to pre-approve 12 skilled nursing visits.
We also decided that the Plan does not have to pre-approve two physical therapy visits.
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 physical therapy visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve two physical therapy visits.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0425, A0427) provided to the enrollee on January 4, 2021.

You asked the Plan to pay for the ambulance services. You say that these services should be separately paid. The Plan denied your request. The Plan says that transportation services are not separately payable from the payment to the inpatient institution.

The Plan must follow Medicare rules. Medicare rules say that ambulance services are separately billable if the Medicare-assigned provider numbers of the two providers are different, if the campuses of the two providers are different, and if the transport is from an inpatient to an outpatient level of care. 

We find that codes A0425 and A0427 are supported in the medical record as being separately billable. Specifically, the Plan found that there is no relationship between the two providers. There is no information to show that the origin provider and the destination provider have the same provider number. Additionally, there is no information to suggest that the two providers share a campus together. We found that the two locations are 17.2 miles/23 minutes apart. Additionally, the Plan found that the enrollee was inpatient at the origin location and was outpatient at the destination. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for ambulance services (A0425, A0427) provided to the enrollee on January 4, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), problem focused limited
oral evaluation (D0140), and extraction (D7210) provided February 16, 2021 by an OON provider.

You asked the Plan to pay for the preventive procedure, problem focused limited oral evaluation, and
extraction. You say that the dentist told you they were in-network. You also say that you added the dental rider
for extended coverage. The Plan denied your request. The Plan says the preventive procedure is not a covered
benefit under your dental plan.

The Plan says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit
plan. The Plan also says that only a 50% coinsurance for the extraction will be covered by the Plan because the
service was received OON.

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, unspecified preventive procedure is not
among those covered under this benefit. The contract says that problem focused limited oral evaluation
(D0140) is limited to one procedure per plan year. The record shows that you received a problem focused
limited oral evaluation (D0140) on January 22, 2021 and your problem focused limited oral evaluation (D0140)
benefit has been exhausted. The Plan contract also says that you are responsible for a 50% coinsurance for
extractions (D7210) plus the difference between the billed amount and allowed amount for services received
OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), problem
focused limited oral evaluation (D0140), and extraction (D7210) provided February 16, 2021 by an OON
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81185, 81401, 81403, 81404, 81406, 81479) provided to the enrollee on October 21, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says this service 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. 

Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81185, 81401, 81403, 81404, 81406, 81479) provided to the enrollee on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, and bitewing
x-rays provided on January 21, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that
you are aware this dentist is OON, but you have been his patient for many years. You also say that you are on a
fixed income and cannot afford the charges. The Plan denied your request. The Plan says the total liability
amount of $109.00 was applied correctly. The Plan also says that the enrollee liability is a contractual
obligation under the Plan and cannot be waived.

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 for services received OON. Therefore, we decided that the Plan
does not have to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on
January 21, 2021 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 9,
2020, to December 31, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care
beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from January 6, 2020,
to November 7, 2020. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
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. Therefore, we decided
that the Plan does not have to pay for the skilled nursing services provided from December 9, 2020, to
December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) and sales tax (D9985) provided on January 19, 2021.

You asked the Plan to pay for the incision and drainage of abscess and sales tax. You say that the treating provider has been your dentist for a while. You also say that you only go to the dentist if needed. The Plan denied your request. The Plan says there is no coverage for the incision and drainage of abscess. The Plan also says that sales tax is not paid when the rendering services are not paid.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incision and drainage of abscess (D7510) and sales tax (D9985) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and the Federally qualified health
center visit (G0467) rendered by the out of network (OON) provider on April 5, 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 Federally qualified health center visit (G0467)
rendered by the out of network (OON) provider on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD). She has not tried and failed the Plan's required drug, Perforomist. The records do not support that the required drug would be contraindicated or less effective; therefore, Brovana is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana.