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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 1, 2018 through August 2, 2018.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because inpatient admission was medically necessary. The Plan denied your request. The Plan says inpatient admission was not medically necessary.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the member's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
 coverage of acute inpatient hospital care have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided August 1, 2018 through August 2, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9500) provided from February 1, 2020, to February 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a valid code. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Procedure code S9500 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 services (S9500) provided from February 1, 2020, to February 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 16, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring facility is out-of-network. The
Plan says that no prior authorization was obtained.
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 has network providers
available who can provide 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 skilled nursing services provided on December 16,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need the diabetic shoes so you can walk and care for yourself and avoid surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on August 29, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code G0483 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes.
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation
of testing of 22 or more drug classes. 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 definitive
drug testing rendered on August 29, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the spinal canal (72148).
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the member
has chronic radicular low back pain and is unable to do physical therapy. The Plan denied your request. The
Plan says that there has been a lack of sufficient time with NASIDs, physical therapy or activity modification.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
member meets Medicare coverage criteria for the MRI. Our physician reviewer found the member has radicular
pain and the MRI is clearly indicated.
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
an MRI of the spinal canal (72148).
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

We decided that the Plan does not have to pay for the ankle foot orthoses provided on December 26, 2019. 
 
You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
There are no medical records to support the diagnosis on the submitted order, therefore the billed codes cannot be supported. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthoses (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses provided on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 20, 2019. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and complete series of intraoral x-rays provided by an out-of-network dentist on January 22, 2020.
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, and complete series of intraoral x-rays. You say that these are preventive dental services. You also say that your coverage states that you only have a $60 copayment to be seen by an out-of-network dentist. The Plan denied your request. The Plan says the treating provider is not part of the Plan's Medicare network and charges more than the Plan's allowed amount for the services provided.
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 dentists can bill you for additional costs if what they charge is more than the maximum benefit amount for preventive services covered by the Plan. Therefore, we decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and complete series of intraoral x-rays provided by an out-of-network dentist on January 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgery services provided on March 14, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for assistant surgery services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services provided on March 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on September
11, 2019.
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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the GeneSight Psychotropic Assay 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
testing was not medically necessary. Our physician reviewer found the enrollee has a diagnosis of major
depressive disorder. The documentation contains an order form that is not signed. The documentation is
insufficient to support that the GeneSight testing meets the criteria for coverage and was reasonable and
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the GeneSight Psychotropic Assay rendered on September 11, 2019.
Local Coverage Determination (LCD) L35062 referenced by the Plan is not binding for the services at issue
and is for the wrong jurisdiction. This LCD was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for Heparin injections and syringes provided on April 1, 2019 through
April 29, 2019. You asked the Plan to pay for the injections and syringes. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says that The heparin
was requested to be used as a flush for the tubing and that is not covered per Medicare rules because the cost of
those supplies is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that outlier payments may be applied in addition to
ESRD PPS payment rates for certain services listed above. The rules also say that ESRD facilities are required
to report all drugs identified in the list found on cms.gov.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the injections and syringes have been met. The drugs and related administration services, such as
use of syringes are listed in the document on cms.gov. This means that they must be reported. The Plan's denial
of the claim based on these codes being reported is not correct. The Plan must process this claim according to
the ESRD PPS rate as well as any applicable outlier payments that may be due. Therefore, we decided that the
Plan has to pay for Heparin injections and syringes provided on April 1, 2019 through April 29, 2019.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT Scan of a lower extremity (73700). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because the CT Scan is medically necessary. The Plan denied your request. The Plan says that the records do not show that the member has failed to improve following a recent six week trial of prescribed treatment. 
 
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 CT Scan. Our reviewer says that the member meets coverage criteria for the CT Scan. Our physician reviewer found the CT Scan is reasonable and indicated given the lack of diagnosis and morbidity of the member's condition. 
 
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 CT Scan have been met. Therefore, we decided that the Plan has to preapprove a CT Scan of a lower extremity (73700).  
 
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 waive the copayment for the inpatient stay provided from September 21, 2019 through September 27, 2019. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that the maximum out-of-pocket was met. You say that the hospital stay was medically necessary and is a covered benefit. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $345 copayment each day for days 1 to 5 for Medicare-covered hospital care. $0 copayment for additional Medicare-covered days.  
 
The enrollee has been asked to pay a $1,725 copayment for the inpatient stay. ($345/day x first 5 days = $1,725). The inpatient stay falls within the "Inpatient Hospital Care" benefit category. The records show that the maximum out-of-pocket had not been met prior to the inpatient stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 21, 2019 through September 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal x-ray (72100) provided on December 5, 2019.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
service 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 72100 is radiologic examination, spine, lumbosacral; 2 or
3 views.
We asked our coder 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 x-ray. Our reviewer says that CPT code 72100 does not
meet criteria for billing or reimbursement consideration. Our reviewer found there is no documentation noted
to support that a radiologic examination was done on the lumbosacral spine.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have
to pay for a spinal x-ray (72100) provided on December 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a non-covered service (A9270) provided on November 1,
2019 through November 29, 2019.
You asked the Plan to pay for the non-covered service. You say that you would like reconsideration because
you did not order any supplies. The Plan denied your request. The Plan says this service processed correctly
because it is a non-covered benefit under your plan.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if
regular Medicare would pay for it in this case.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the non-covered service have not been met. Specifically, this service is a non-covered benefit
under Medicare. Therefore, we decided that the Plan does not have to pay for a non-covered service (A9270)
provided on November 1, 2019 through November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system.
You asked the Plan to pre-approve a Freestyle Libre CGM system. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 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 pre-approve a Freestyle Libre CGM system. Our reviewer says that the item is not medically necessary. Our physician reviewer found in this case, the most recent records from your physician do not document the frequency of your blood glucose checks or that you use the results to self-adjust your insulin doses. The review has determined that you do not meet the criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on January 16, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you noticed an infection which was causing severe pain. You also say that your dentist gave you the choice of an extraction or endodontic treatment, and you chose the endodontic treatment to save your tooth. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances. 
 
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 endodontic therapy (D3310) provided on January 16, 2020.