Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the positive airway pressure device supplies provided on February 5, 2021 by an out-of-network provider.
You asked the Plan to reimburse you for the positive airway pressure device supplies. You say that the supplies are covered, and you want to be reimbursed as the money the supplier has taken from your account has created a hardship. The Plan denied your request. The Plan says the services are not urgent or emergent, nor were they approved in advance.
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 reimburse you 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the Plan does not have to reimburse you for the positive airway pressure device supplies provided on February 5, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive pharmacogenomics panel (81105, 81112, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81350, 81355, 81400, 81401, 81479) provided on January 13, 2021.
You asked the Plan to pay for a comprehensive pharmacogenomics panel. You say that this is the only laboratory that can perform this testing. The Plan denied your request. The Plan says this was not billed correctly.
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 81105, 81112, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81350, 81355, 81400, 81401, and 81479 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a comprehensive pharmacogenomics panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive pharmacogenomics panel (81105, 81112, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81350, 81355, 81400, 81401, 81479) provided on January 13, 2021.
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 the enrollee will clearly benefit from acute rehab to optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee's wound care it not complex and there are no complex rehab conditions.
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. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on October 6, 2020.
You asked the Plan to pay for the dental service. You say that your dentist advised that none of the work is cosmetic. You say that you do not understand the purpose of paying for this insurance if everything is denied. You also say that you would like to understand the purpose of this insurance. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as a covered service.
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 comprehensive periododontal
evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous process distraction device implantation.
You asked the Plan to pre-approve interspinous process distraction device (implantable) (C1821). You say that
the minimally invasive implantation of a posterior interspinous process spacer device is the most appropriate
treatment for the enrollee. The Plan denied your request. The Plan says a review of the current medical
literature indicates that this service is considered experimental and investigational.
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 interspinous process distraction device
(implantable) (C1821). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found spinous process distraction devices remain
experimental. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of interspinous process distraction device (implantable) (C1821) have not been
met. Therefore, we decided that the Plan does not have to pre-approve an interspinous process distraction
device implantation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the technical components (TC) of the intraoperative neuromonitoring (IONM) services provided on March 8, 2021, billed with codes 95861, 95938, and 95957.
You asked the Plan to pay for the TC of the IONM services. You say that this should be paid as the supplies are not provided by the facility. The Plan denied your request. The Plan says these services cannot be paid by Medicare.
The Plan must follow Medicare rules. Medicare rules say that payment for all items and non-physician services rendered to registered inpatients are included in the inpatient facility payment. The TC component of these services does not include physician work. This means that the TC of these services included items and non-physician services. Payment for this is made to the facility in the PPS payment.
Therefore, we decided that the Plan does not have to pay for the technical components (TC) of the intraoperative neuromonitoring (IONM) services provided on March 8, 2021, billed with codes 95861, 95938, and 95957.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a Medicare benefit. The Plan denied your request. The Plan says rules for coverage for a Vertiflex procedure have not been met because the requested procedure is experimental/investigational.
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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex spacer device is experimental. More research is needed to show safety and efficacy.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after August 28, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says the 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 91-year-old female with pneumonia. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Therefore, you do 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after August 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for services you received from an
ophthalmology specialist on April 27, 2021.
You asked the Plan to waive the copayment for the ophthalmology services. You say that you do not think you
should have a copayment for this service. The Plan denied your request. The Plan says you were charged this
copayment 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). Your contract with the Plan clearly says that you must pay a $40
copayment for services with a specialist.
You have been asked to pay a $40 copayment for the ophthalmology services. The ophthalmology services fall
within the services with a specialist 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
services you received from an ophthalmology specialist on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab service provided on September 13, 2020.

You asked the Plan to pay for the lab services. You say that Coronavirus testing should be covered in full. The Plan denied your request. The Plan says an appropriate modifier was not 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 87486 is infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique. We find that CPT code 87486 was billed with code 87150. These codes have a PTP edit of 1. The billed claim does not show that a PTP-associated modifier was used for the code at issue. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab service provided on September 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January
22, 2021 to January 28, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare guidance says code HCPCS code S9367 is assigned a status code of "I" which
is statutorily excluded. Medicare uses another code for the reporting of this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to the
status indicator for the code billed. Medicare rules for coverage of this service have not been met. Therefore,
we decided that the Plan does not have to pay for home health services provided to the enrollee from January
22, 2021 to January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on April 14, 2021.
You asked the Plan to pay for the 2D oral/facial photographic images, complete series of intraoral x-rays, and panoramic x-ray. You say that prior to receiving these services you asked the secretary if this visit was approved by the Plan and they told you yes. You also say that you do not have the money to pay for these services. The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered service. The Plan also says that your benefits for the complete series of intraoral x-rays and panoramic x-ray have been satisfied and the frequency limitation has been exceeded.
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, 2D oral/facial photographic image (D0350) is not among those covered under this benefit. The contract says that full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a complete series of intraoral x-rays on November 18, 2019 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on April 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility services.
You asked the Plan to pre-approve the continued skilled nursing facility services. You say that additional skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says your benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care as of August 29, 2021. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assay (lab service) provided to the enrollee on March 4, 2021.

You asked the Plan to pay for this lab service. You say that this claim should be paid. The Plan denied your request. The Plan says this test was ordered as a screening and is not covered by Medicare.

The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. The test at issue in this appeal 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 cardiovascular risk assay (lab service) provided to the enrollee on March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the x-ray. You say that the current procedure terminology (CPT) code 73501 is not listed as needing an authorization. The Plan denied your request. The Plan says 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 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 the x-ray provided on April 6, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network neurologist.
You asked the Plan to pre-approve office visits to be provided by an out-of-network neurologist. You say that you want to see this out-of-network specialist. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network neurologist.
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 you need IRF care. The Plan denied your request. The Plan says the rules for IRF care have not been met.
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. Our physician reviewer found that you was admitted for surgical repair of a hip fracture after a fall. 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. In conclusion, 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. 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.