Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management services, direct patient care first hour (99358) each additional 30 minutes (list separately in addition to code for prolonged service) (99359) provided on February 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services. You say that your doctor provided medical necessity service to the enrollee in good faith, and in return you are expected reimbursement. Please review the enclosed documentation and reprocess the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management services, direct patient care first hour (99358) each additional 30 minutes (list separately in addition to code for prolonged service) (99359) provided on February 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that in the case of a clinical laboratory test provided under an arrangement made by a hospital, CAH or SNF, payment is made to the hospital or SNF. We looked at the file and Medicare rules. The file shows that the laboratory services were provided under arrangement by a hospital and payment is made to the hospital. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz.
You asked the Plan to pre-approve Xeljanz. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Xeljanz.
Benefits for Xeljanz 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deducible for the resin-based filling (D2330) provided on May 5, 2021.
You asked the Plan to waive the deducible for the dental service. You say that it isn't fair to charge a deductible for supplemental services when you already pay an extra monthly premium for the comprehensive coverage. The Plan denied your request. The Plan says comprehensive dental services require a $100 deductible, which was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $100 deductible for comprehensive dental services. The item or service you asked the Plan to waive the deducible for is a comprehensive dental service. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible for comprehensive dental services. This cost sharing is a contractual obligation that had not been met at the time
the dental service was received on May 5, 2021. Therefore, we decided that the Plan does not have to waive the deducible for the resin-based filling (D2330) provided on May 5, 2021.
Your complaint about the coverage and cost of the Plan's supplemental benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
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). An independent laboratory taking a sample in its laboratory shows "81" as place of service. You can find this information in the Medicare Claims Processing Manual, Chapter 26, Section 10.6. The rules say that for all services (with two (2) exceptions), the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place. You can find this information in the MLN Matters article number MM7631, "Revised and Clarified Place of Service (POS) Coding Instructions".
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for SNF care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested services are medically necessary for the enrollee. Our physician reviewer found that there is no documentation that the enrollee requires skilled nursing services; that is, the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. However, the enrollee does require skilled therapy services; that is, the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment due to a documented decline in function with activities of daily living. Based on the medical records provided, it is medically reasonable and necessary to provide these skilled services on a daily basis. The enrollee does require the services on an inpatient basis in a skilled nursing facility setting for physical therapy and occupational therapy services due to documented decline in function. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
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 these services are medically necessary. The Plan denied your request. The Plan says that this request exceeds the member's needs.
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. 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 have a past medical history of arthritis and hypertension and are living at home with trouble walking despite home health physical therapy. Your medical
problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 rendered on February 26, 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 in the Medicare rules section, 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 February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81355, 81381, 81240, 81241, 81283, 81328, 81335, 81350, 81225, 81226, 81227, 81230, 81231 and 81232 provided on January 31, 2021.
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 are not payable as 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. We find that CPT codes 81355, 81381, 81240, 81241, 81283, 81328, 81335, 81350, 81225, 81226, 81227, 81230, 81231 and 81232 are not supported in the medical record. Specifically, the documentation shows that the enrollee had molecular pharmacogenetic testing. Medicare denies coverage when a laboratory assays two or more genes in an enrollee in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 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 81355, 81381, 81240, 81241, 81283, 81328, 81335, 81350, 81225, 81226, 81227, 81230, 81231 and 81232 provided on January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on April 6, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the charge should be considered part of the dental cleaning and the dentist needs to recode this. The Plan denied your request. The Plan says a comprehensive oral exam is only covered once 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, a comprehensive oral exam is only
covered once every three years. The Plan paid for a comprehensive oral evaluation provided on March 24,
2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the
comprehensive periodontal evaluation provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture provided on August 17, 2020.
You asked the Plan to pay for the complete upper denture. You say that you paid for the services out-of-pocket and want to be reimbursed. The Plan denied your request. The Plan says dental services are only covered when received from an in-network 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture provided on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on December 2, 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the definitive drug testing rendered on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702)
You asked the Plan to pre-approve the orthotic device. You say that this device is intended for permanent, daily functional restoration of an arm rendered chronically impaired and resistant to alternative rehabilitation techniques. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on March 22, 2021.
You asked the Plan to pay an additional amount for a comprehensive oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images. You say that you were not informed you needed to use an in-network provider. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made.
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. physician reviewer found We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a teeth cleaning, and an intraoral complete series of radiographic images have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a teeth cleaning (D1110), and an intraoral complete series of radiographic images (D0210) provided on March 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records do not show that you require daily skilled nursing or skilled rehabilitation services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pristiq tablets.

You asked the Plan to pre-approve Pristiq tablets. You say that the enrollee breaks out in hives on other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's presciption drug plan.

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 Pristiq tablets.

Benefits for Pristiq tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional chiropractic visits, for the enrollee.

You asked the Plan to pre-approve the chiropractic visits. You say that it is medically necessary based on segmental and somatic dysfunction of lumbar region. The Plan denied your request. The Plan says there is nothing in the supplied documentation that supports that the services will be of such a level of complexity and sophistication, or the condition of the enrollee will be such that the services required can be safely and effectively performed only by a chiropractor or under a chiropractor's supervision vs. HEP after the total approved visits.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 

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 chiropractic services. Our physician reviewer found the available documentation does not support a reasonable expectation of recovery or improvement of function. 

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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional chiropractic visits, for the enrollee.