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

We decided that the Plan does not have to pay for speech therapy services (CPT 92522) provided to the enrollee from January 11, 2021 to January 13, 2020.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the billed services were 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 92522 is "Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 92522 is not a timed procedure code. Medicare specifies that evaluation or assessment procedures may be billed only once per discipline, per date of service, per patient (CPT 92521, 92522, 92523, 92524, 92597, 92607, 92611, 92612, 92616).
Additionally, treatment codes may be subject to Medicare's Medically Unlikely Edits (MUEs), which specify how many times a code may be billed per date of service. The MUE for CPT 92522 (value 1) prevents this code from being billed more than once in a day. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for speech therapy services (CPT 92522) provided to the enrollee from January 11, 2021 to January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. You do not appear to require inpatient mental health treatment as you were not a danger to yourself or others, have no auditory or visual hallucinations while being cooperative with treatment. It does not appear that active treatment is taking place. It does not appear that services are reasonably expected to improve your condition or for the purpose of diagnosis. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric 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 psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the prophylaxis (D1110) provided on February 4, 2021.
You asked the Plan to pay for the prophylaxis. You say that you would like reconsideration because this dentist was listed in your Plan's database. The Plan denied your request. The Plan says that this dentist has opted out of Medicare.
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. The Plan covers the prophylaxis when the services are rendered by a participating provider. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the prophylaxis have been met. Specifically, the contract does not clearly indicate that the provider must accept Medicare assignment. The Plan has confirmed that this provider is in-network with the member's dental benefit plan. Additionally, the Plan has failed to forward the 2021 Evidence of Coverage showing why this service would not be a covered benefit. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the prophylaxis (D1110) provided on February 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing (81479, 81391) provided on December 16,
2020.
You asked the Plan to pay for GeneSight testing. You say that the enrollee clearly meets GeneSight criteria for
testing. The Plan denied your request. The Plan says this testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics (PGx) tests must demonstrate
analytical validity, clinical validity, and clinical utility to be considered reasonable and necessary for coverage.
This is demonstrated through a required technical assessment of the test. PGx tests are considered germline
tests and must adhere to other relevant germline testing policies published by this contractor.
We looked at the file and Medicare rules. The testing at issue has not undergone a technical assessment and is
not covered by the Medicare contractor. Based on this information, we decided that Medicare rules for
coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for
GeneSight testing (81479, 81391) provided on December 16, 2020.
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 although you do require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment, there is no documentation that you require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. In addition, daily skilled services are not required. In conclusion, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on January 22, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with a statement of medical necessity and test request form from the enrollee's in-network treating physician. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. You say that this testing was ordered by the enrollee's in-network treating physician. The documentation does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on January 22, 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: DME/ Orthotics
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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
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: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 21, 2020, to November 19, 2020.
You asked the Plan to pay for SNF care. You say that these services should be covered by Medicare. The Plan denied your request. The Plan says the enrollee did not have skilled needs.
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 pay for SNF care. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found the documentation does not show that the enrollee required complex wound care, new enteral feedings, or other skilled nursing services during the dates in question. The enrollee's functional level did not require skilled therapy services. As a practical matter, the enrollee did not require services on an inpatient basis in a skilled nursing facility setting during the dates in question. 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 pay for skilled nursing facility (SNF) care provided from October 21, 2020, to November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #3 and retainer crowns (D6740) for teeth #2 and #4.
You asked the Plan to pre-approve the bridgework. You say that you do not want a denture and this service is necessary. Your current bridge is over 30 years old and is falling apart. You believe fixing this bridge will also be more affordable than a denture. The Plan denied your request. The Plan says a new bridge is not medically necessary. The information provided shows this denture is not missing or having issues. There are no cavities. A request for a new bridge cannot be supported at this time.
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. The Plan covers the bridgework when the services are medically necessary and reasonable. 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 bridgework. Our reviewer says that the requested services are not necessary. Our physician reviewer found the documentation provided does not meet the criteria for coverage for the replacement of the current fixed bridge replacing tooth #3.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bridgework have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #3 and retainer crowns (D6740) for teeth #2 and #4.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because
the SNF admission should be approved for coverage. The Plan denied your request. The Plan says the enrollee
requires no nursing services which would be considered skilled services by Medicare.
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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for onabotulinumtoxina injection (Current
Procedural Terminology (CPT) code J0585) provided on October 2, 2020.

You asked the Plan to waive the copayment for the medication. You say that you should only have a $40
specialist copayment and should not be charged for the medicaiton you received. The Plan denied your request.
The Plan says the claim was processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received an onabotulinumtoxina injection (CPT code J0585) on October 2,
2020. You have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed
amount is $1,216. The total you owe is $243.20 ($1,216 x 20% = $243.20). 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 onabotulinumtoxina injection (Current Procedural Terminology (CPT) code J0585) provided on October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with an elevating seat function/tilt or lift option.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says you previously have been provided with an electric wheelchair which meets your needs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the patient meets Medicare criteria for the elevating seat function. A power seat elevation feature and a power standing feature are not covered by Medicare as they are not primarily medical in nature. The health plan has already approved a power wheelchair without an elevating seat function for the enrollee. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with an elevating seat function/tilt or lift option.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the heart for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show any signs or symptoms of heart disease.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has an intermediate cardiovascular risk. A decision to utilize statins has not been made. The enrollee does not have a familial history of hypercholesterolemia. The requested service is medically necessary and reasonable as defined by Medicare rules. The elements of the coverage criteria are satisfied. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the heart for the enrollee.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided December 16, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the CPT code 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 code 97110 is not supported in the medical record. Specifically, the records show the
services were provided in the home setting. There is a more appropriate CPT code for this service (G0157).
Based on this information, we decided that Medicare rules for coverage of the therapy services have not been
met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided December
16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee 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 for the enrollee. The enrollee is medically stable and has been provided medical clearance to undergo a reverse total shoulder arthroplasty and associated procedures. The planned procedure listed under CPT codes 23472, 24301 and 23020 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 the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's 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 for the enrollee.