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

We decided that the Plan does not have to pay for continued SNF services provided from December 16, 2020, through December 19, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says there are no daily skilled needs after December 15, 2020.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from December 16, 2020 through December 19, 2020. The buttock wound was reported to be resolved as of December 16, 2020 and the enrollee had completed antibiotics
for the urinary tract infection. The medical records do not document any other acute issue during this period necessitating skilled care. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment from December 16, 2020 through December 19, 2020. The buttock wound was reported to be resolved as of December 16, 2020 and the enrollee had completed antibiotics for the urinary tract infection. The medical records do not document any other acute issue during this period necessitating skilled care. Daily skilled services were not required from December 16, 2020 through December 19, 2020. The buttock wound was reported to be resolved as of December 16, 2020 and he had completed antibiotics for the urinary tract infection. The medical records do not document any other acute issue during this period necessitating skilled care. As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from December 16, 2020 through December 19, 2020. The buttock wound was reported to be resolved as of December 16, 2020 and he had completed antibiotics for the urinary tract infection. The medical records do not document any other acute issue during this period necessitating skilled care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the continued SNF services provided from December 16, 2020, through December 19, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on
December 19, 2020.
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you were
admitted to the hospital and thought that the copayment would be waived. The Plan denied your request. The
Plan says the claims were processed correctly, and you are being charged the correct amount.
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 $275
copayment for outpatient hospital observation.
The record shows that you received outpatient hospital observation on December 19, 2020. Therefore, you are
responsible to pay the $275 copayment.
You have been asked to pay a $275 copayment for outpatient hospital observation. Outpatient hospital
observation falls within the outpatient hospital observation 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 outpatient hospital observation provided on December 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 18, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation

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 80307 and G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) debridement (11044) provided on November 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that medically necessary services were provided on request of the Medical Director/PCP. You have attached medical documentation supporting the need for the services that were rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99308) debridement (11044) provided on November 6, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Drug test def 1-7 classes, 2 units (G0480) provided from January 13, 2020 to January 15, 2020.

You asked the Plan to pay for Drug test def 1-7 classes, 2 units (G0480). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim exceeds the MUE indicator.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code G0480 is 1. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of Drug test def 1-7 classes, 2 units (G0480) have not been met. Therefore, we decided that the Plan does not have to pay for Drug test def 1-7 classes, 2 units (G0480) provided from January 13, 2020 to January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 72125) provided to the enrollee on September 13, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code remains 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 72125 is "computed tomography, cervical spine; without contrast material." 

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 CT of the chest, abdomen and pelvis was done 9/13/20 with report of exams included. There is no documentation in the form of a transcribed CT cervical spine, CPT 72125 on that date. Absent a formal report in the submitted records there is no justification for reimbursement for CT cervical spine on 9/13/20. 

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 radiology services (CPT 72125) provided to the enrollee on September 13, 2020.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member requires 24-hour nursing care with daily physician oversight. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for necrosis of the foot and peripheral vascular disease and had an above the knee amputation. The enrollee's medical problems are stable. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home
use provided on February 10, 2021.

You asked the Plan to pay for the drugs or medicaments. You say that you would like to appeal this service.
The Plan denied your request. The Plan says this service is not a covered 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, 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 drugs
or medicaments dispensed in the office for home use provided on February 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for computerized ophthalmic diagnostic imaging (eye imaging) and an eye examination provided on January 4, 2021.

You asked the Plan to waive the copayments for eye imaging and eye exam. You say that you already paid $45 at the visit and these charges should be reviewed. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

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 $50 copayment for eye imaging and $45 copayment for eye exam. For the eye imaging you have been asked to pay the allowed amount of $28.87, because this amount is less than the $50 copayment for diagnostic tests. Your total copayment obligation is therefore $73.87. 

You have been asked to pay less than $50 copayment for eye imaging and $45 copayment for eye exam. Eye imaging and eye exam fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Vision Care" benefit categories. 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 copayments for computerized ophthalmic diagnostic imaging (eye imaging) and an eye examination provided on January 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Abatacept injection.

You asked the Plan to pre-approve the Abatacept injection. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Abatacept injection. Our reviewer says that the Plan requires a trial of Avsola, Inflectra, Renflexis or Simponi Aria before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects 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 Abatacept injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the Abatacept injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid fitting and check (V5011) provided on
December 14, 2020.
You asked the Plan to pay for the hearing aid fitting and check. You say that you needed this hearing aid
recalibration. The Plan denied your request. The Plan says three visits within the first year of a hearing aid
purchase can be covered. Your third visit occurred on November 10, 2020, and as a result, the visit in question
is not covered as part of your hearing aid benefit. The Plan also confirmed that you paid $50 at the time of
service but were billed for the remaining amount afterward. As a result of the Plan's investigation, the office
has decided to write off this amount and you are not responsible for any amount greater than the $50 paid at the
time of service.
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 will cover
up to three provider visits within the first year following a purchase of hearing aids.
We looked at the file and the Plan's rules. Documentation shows that the hearing aids were purchased on
November 21, 2019, which is more than one year before the date in question. In addition, the purchase
agreement form that you signed at the time of purchase states that three follow up visits are included within the
first year of purchase. Additional visits, and visits after the first year will be charged at $25 per hearing aid. The
Plan has indicated that the provider agreed to leave the bill at the $50 paid at the time of service, which follows
this signed agreement.
Based on this information, we decided that the Plan's rules for coverage of the hearing aid fitting and check
have not been met, as the follow-ups can only be covered within year from the date of purchase. Therefore, we
decided that the Plan does not have to pay for the hearing aid fitting and check (V5011) provided on December
14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0481) provided on September 24, 2020.

You asked the Plan to pay for drug testing. You say that these tests should be covered. The Plan denied your request. The Plan says these tests were billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0481) provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on May 19, 2020 by an OON provider.
You asked the Plan to pay for the outpatient office visit. You say that the service provided were medically necessary. The Plan denied your request. The Plan says the enrollee was not referred to this OON provider by their primary care provider. The Plan also says that a prior authorization was not 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 outpatient office visit provided on May 19, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure
(CPAP) machine provided November 19, 2020.
You asked the Plan to waive the coinsurance for the CPAP machine. You say that you do not believe you
should be charged a coinsurance for a device you are returning. The Plan denied your request. The Plan says
the coinsurance has processed correctly, and no reimbursement is due.
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 20%
coinsurance for durable medical equipment.
You have been asked to pay a total cost share of $105.08 for the CPAP machine ($525.42 Medicare allowed
amount x 20% coinsurance). This service falls within the durable medical equipment 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 coinsurance for the continuous positive airway pressure (CPAP) machine
provided November 19, 2020.
Your complaint about the potential sharing of your information with a third party without your consent is not a
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: 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 you would like reconsideration because the LTACH admission is medically necessary The Plan denied your request. The Plan says the member can adequately receive care needed for ongoing ventilator weaning in current their setting.
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 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. 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.