Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show enrollment in a clinical trial.

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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found any potential benefit or detriment of proton therapy over standard IMRT is an investigational question (being pursued in randomized studies- i.e. for intermediate to low risk prostate cancer. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.

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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid exam.

You asked the Plan to pay for the hearing aid exam. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says hearing aid exams are only covered when provided by a contracted 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. The Plan pays for hearing aids exams only when provided by a contracted provider.

We looked at the file and the Plan's rules. The Plan's contract clearly says hearing aid exams are only covered when provided by a contracted provider. The file shows that the provider in this case was not a contracted provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid exam have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid exam.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing with CPT code 95999.

You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan 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 95999 is Unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing with CPT code 95999.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy services provided from May 5, 2020 to October 30, 2020.

You asked the Plan to waive the copayments for physical therapy. You say that you received a notice that all out-of-pocket costs would be waived effective May 1, 2020 to December 31, 2020. The Plan denied your request. The Plan says the cost-sharing waiver applies to primary care, outpatient behavioral health and telehealth services. The services at issue are outpatient rehabilitation services, which still have a $10 copayment for each day that you receive therapy.

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 copayment for outpatient rehabilitation services. 

You have been asked to pay a $420 copayment for 42 days of physical therapy provided between May 5, 2020 and October 30, 2020. Physical therapy falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your original 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 physical therapy services provided from May 5, 2020 to October 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee had stabilized medically and has been receiving skilled services in a long-term acute care hospital (LTACH). His progress with therapy was limited due to his baseline cognitive impairment. The enrollee did not continue to require skilled nursing and/or skilled therapy services on a daily basis. Although the enrollee was making slow progress with therapy, there was no indication that transfer to a skilled nursing facility was required. The enrollee could have continued to receive skilled services at the level of care in an LTACH or been stepped-down to a lower level of care for intermittent services if needed. There are no services offered at a SNF that are not offered at a LTACH. Admission to a skilled nursing facility for inpatient skilled services was not medically necessary at the time of the request.

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 an inpatient skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.

Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.

We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening services (G0103).

You asked the Plan to pay for the prostate cancer screening services. You say that you feel you should not be responsible for this amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received your third prostate cancer screening exam within the last 12 months on the date of service at issue in this appeal. The Plan says you are only covered for one screening every 12 months.

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 $0 copayment for Prostate cancer screening exams. This service is only covered once every 12 months.

We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly says you are covered for one prostate cancer screening exam every 12 months. The file shows that the prostate cancer screening exam you received is the third exam you have received in the last 12 months. The Plan previously paid for these services. Therefore, we decided that the Plan does not have to pay for the prostate cancer screening services (G0103).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth 4.

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 covered.

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 pre-approve endodontic therapy for tooth 4.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing.

You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan 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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided by a participating hospital on September 8, 2020, to October 13, 2020.
You asked the Plan to waive the copayment for lab services. You say that you think this is being incorrectly billed. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $50 copayment for outpatient hospital services/in-network/lab services. You have been asked to pay a $50 copayment for lab services. The total amount you are being asked to pay is $83.88 ($50 + $33.88 = $83.88). Lab services fall within the outpatient hospital services/in-network/lab 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 copayment for lab services provided on September 8, 2020, to October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from a network provider. In most cases, care received from an out-of-network provider will not be covered, with the following three exceptions: emergency care or urgently needed services, Medicare covered medical care that the providers in our network cannot provide, and dialysis services at a Medicare certified dialysis facility when you are temporarily outside the Plan's service area. A prior authorization is required if you are seeking non-emergency out-of-network care.

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 did not pre-approve the physician's services. 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 physician's services provided on October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (Vertiflex Superion device) (22869).
You asked the Plan to pre-approve the Vertiflex Superion device. You say that you feel the following treatment would be the safest and most effective course of action. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. The plan considers these types of systems unproven and not medically necessary. More research is needed to show safety and efficacy.
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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (Vertiflex Superion device) (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 6, 2020.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says service was rendered by a non-contracted provider, which requires authorization and there is not one on file.

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 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 subsequent nursing facility care provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.

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 covered.

The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is non-covered. 

We looked at the file and Medicare rules. The services at issue are a power seat elevation feature. These services are not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Watchman procedure.

You asked the Plan to pay for the Watchman procedure. You say that the Watchman procedure provided was medically necessary. The Plan denied your request. The Plan says the Watchman procedure provided was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Watchman procedure. Our reviewer says that the Watchman procedure provided was not medically necessary. Our physician reviewer found based on the records the enrollee has atrial fibrillation but there is no documentation of a contraindication to anticoagulation and no documentation of a formal shared decision making process. Coverage criteria are therefore not met since those require "A formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. The shared decision making interaction must be documented in the medical record. And "A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants." 

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 Watchman procedure provided have not been met. Therefore, we decided that the Plan does not have to pay for the Watchman procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services with dental codes D0140, D0220, and D2740 provided on May 28, 2020.

You asked the Plan to pay additionally for dental codes D0140, D0220, and D2740. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the dental claims processed correctly.

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.

We looked at the file, the Plan's contract and Medicare rules. The file shows the provider billed service D0140 in the amount of $92. The allowed amount for the service is $44. The Plan pays 100% of the allowable amount per the benefits outlined in the Evidence of Coverage (EOC). The Plan paid $44. You are responsible for all fees billed by the provider in excess of the allowed amount $48 ($92 - $44). Your liability for dental code D0140 is $48.

The file shows the provider billed service D0220 in the amount of $45. The allowed amount for the service is $15. The Plan pays 100% of the allowable amount per the benefits outlined in the EOC. The Plan paid $15. You are responsible for all fees billed by the provider in excess of the allowed amount $30 ($45 - $15). Your liability for dental code D0220 is $30.

The file shows that provider billed service D2740 in the amount of $1290. The allowed amount for the service is $649. The Plan pays 50% of the allowable amount per the benefits outlined in the EOC. The Plan paid $324.50. You are responsible for all fees billed by the provider in excess of the allowed amount $965.50 ($1290 - $324.50). Your liability for dental code D2740 is $965.50. 

Therefore, we decided that the Plan does not have to pay additionally for the dental services with dental codes D0140, D0220, and D2740 provided on May 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285) and related services (96365, 96366, 36415, 80053, 81003, 87070, 87075, 87205, 82550, 85025, 85610, 71045, 70450, 93005, J1335, J3370).

You asked the Plan to pay for an emergency room visit and related services. You say that these services should be covered. The Plan denied your request. The Plan says these services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that all Indian Health Services (IHS) charges, except for the exceptions listed above, are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).

We looked at the file and Medicare rules. The services at issue were not reported under revenue code 0510. Based on this information, we decided that Medicare rules for coverage of an emergency room visit and related services have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285) and related services (96365, 96366, 36415, 80053, 81003, 87070, 87075, 87205, 82550, 85025, 85610, 71045, 70450, 93005, J1335, J3370).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services with dental codes D0140, D0220, D0230, D7210, and D9120.

You asked the Plan to pay for dental codes D0140, D0220, D0230, D7210, and D9120. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D0140, D0220, D0230, D7210, and D9120 are not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D0140, D0220, D0230, D7210, and D9120 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with dental codes D0140, D0220, D0230, D7210, and D9120.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services.