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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after August 21, 2021.
You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.
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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after August 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SPECT test provided on April 21, 2021.

You asked the Plan to waive the copayment for the SPECT test. You say that you did not know there was a copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $75 copayment per visit for Medicare-covered diagnostic radiology services such as MRI, CT, and PET scans (not including x-rays).

You have been asked to pay a $75 copayment for the SPECT test. The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received a myocardial perfusion imaging test. 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 the SPECT test provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the ECG provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and the ECG. You say that the services were medically necessary. 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 office visit and the ECG provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient stay provided from October 9, 2020, to October 
14, 2020. 
 
You asked the Plan to pay for the inpatient stay. You say that you would like this claim to be processed for 
payment. The Plan denied your request. The Plan says the enrollee was not experiencing any signs of 
withdrawal nor had any risk factors suggestive that inpatient detox was necessary. The Plan also says that the 
appropriate level of care would have been outpatient. 
 
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 pay for the inpatient stay. Our reviewer says that 
these services were not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
records provided in cases such as this an evidence-based, objective, instrument such as the American 
Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining 
necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of 
current suicidal ideation and no self-harming behaviors. Our reviewer found that with regards to functional 
status, the records support a score of 1 due to minimal impairment in function. In terms of medical, addictive 
and psychiatric comorbidity, the records support a score of 1 no comorbidity as his chronic obstructive 
pulmonary disease was previously treated. In terms of level of stress of the recovery environment, the records 
support a score of 1 due to a stable living situation. With regards to level of support for the recovery 
environment, the records support a score of 1 due to support. With regards to treatment and recovery history, 
the records support a score of 1 due to fully responsive to treatment and recovery management. Our physician 
reviewer also found that in terms of engagement and recovery status, the records support a score of 1 due to 
cooperation in treatment and insight into his need for treatment along with insight into her treatment needs. 
Thus, the enrollee has a composite score of 7. This correlates with treatment in a community-based outpatient 
clinic 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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from October 9, 2020, to October 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home skilled nursing visits and 16 additional therapy visits.

You asked the Plan to pre-approve the additional therapy and nursing visits. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 additional therapy and nursing visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that supports that the denied nursing visits meet Medicare criteria for coverage. Records do not document any unstable medical conditions of change in condition to necessitate additional skilled nursing or therapy visits beyond what has already been approved 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 additional therapy and nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home skilled nursing visits and 16 additional therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80306) provided July 2, 2019.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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 80306 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, CPT 80306 has a professional component / technical component listing of 9 and cannot be paid with modifier 26. 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 lab services (80306) provided July 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.
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 you 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 is not medically reasonable and necessary in this case. You have left hip pain related to osteoarthritis and are scheduled for a planned elective left hip arthroplasty. You were stable and had no significant medical history which would suggest you would require hospital services that would likely cross 2 midnights. Our physician reviewer found that your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on December 21, 2020, billed with codes 34709 and 35355.

You asked the Plan to pay for the surgical services as billed. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says the codes billed are not supported by the records.

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 34709 is placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure). The definition of code 35355 is Thromboendarterectomy, including patch graft, if performed; iliofemoral. 

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 surgical services as billed. Our reviewer says that the documentation does not support the billed services. Our reviewer found Operative report does not clearly document the full description of both procedures to confirm procedures were performed. For CPT 34709 "Per operative report "Then I advanced the 17 Fr sheath on the right limb and I loaded a 25 x 75 Vela extension, I shoot aortagram the lower left renal was occluded. The right was open. Due to the significant amount of clot in the CTA and since I had at least 15 mm of neck below the occluded renal I went below it. And stayed lower of the right renal. Performed final angiogram that didn't show any endoleaks. I balloon angioplasty the iliac limbs with kissing balloons and the mid part of the aortic graft with a larger balloon. I did a completion angiogram to make sure that the external iliac are free of disease". Documentation does not include all procedures that are in the description of these codes, and therefore, cannot be verified as performed. 

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 surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on December 21, 2020, billed with codes 34709 and 35355.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay
provided from December 30, 2020, to January 31, 2021.

You asked the Plan to waive the copayment for SNF stay. You say that this provider did not help the enrollee
so you do not feel there should be a copayment. The Plan denied your request. The Plan says the copayment
amount the enrollee is being charged is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $20 copayment per day for days 1 to 20 and $150 copayment per day for days 21 to 34 for SNF stay.
This SNF stay period lasted 33 days, resulting in a copayment amount of $2,350; however, the enrollee has
only been asked to pay a total of $2,090.

The enrollee has been asked to pay less than $20 copayment per day for days 1 to 20 and $150 copayment per
day for days 21 to 34 for SNF stay. SNF stay falls within the Skilled Nursing Facility (SNF) Care benefit
category. 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 a skilled nursing facility (SNF)
stay provided from December 30, 2020, to January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for digital binaural hearing aids (V5261) and an electroacoustic evaluation for hearing aids (92595) provided on October 9, 2020.

You asked the Plan to pay for the hearing aid services. You say that you called customer service and were only told that you had a $2,500 benefit for hearing aids. No other limitations or exclusions were mentioned. You purchased these hearing aids because they offered the best results and extra features and feel the Plan should pay for them up to the benefit limit. The Plan denied your request. The Plan says hearing aids are not covered by Medicare and the provided services are not covered by the Plan's supplemental benefit.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays only for standard (analog or basic) hearing aids and standard hearing aid tests. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid services have not been met. Therefore, we decided that the Plan does not have to pay for digital binaural hearing aids (V5261) and an electroacoustic evaluation for hearing aids (92595) provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low frequency, non-contact, non-thermal ultrasound.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a chronic foot ulceration. There is insufficient scientific or clinical evidence to support the use of low frequency, non-contact, non-thermal ultrasound for the treatment of wounds. The services are considered experimental in nature and not medically necessary.
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 pre-approve a low frequency, non-contact, non-thermal ultrasound.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the crown (D2740) and core build up (D2950) provided on February 20, 2021.

You asked the Plan to waive the cost share amount for the dental service. You say that your provider did not inform you that alternative materials were used for your procedure. You say that you received approval for both materials. You also say that this should be partially covered. The Plan denied your request. The Plan says there is a 50% coinsurance for Class 3 Major Services, including a crown and core build up. The Plan says that the Evidence of Coverage did not clearly explain the cost share for an alternative benefit for crown and will waive this portion of the bill. The Plan also says that you are still responsible for the 50% coinsurance for the crown and core build up.

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 and the services are listed as covered, there is a 50% coinsurance for Class 3 Major Services. Therefore, we decided that the Plan does not have to waive the full cost share amount for the crown (D2740) and core build up (D2950) provided on February 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2) and two abutment supported porcelain/ceramic crowns (D6058 x2) provided on May 12, 2021.

You asked the Plan to pay for the custom fabricated abutments and abutment supported porcelain/ceramic crowns. You say that your dental office did not advise you that your allowance for these services had been met.

The Plan denied your request. The Plan says the implant service benefit has a limit to two in a calendar year. The Plan also says that your history plus this request has gone over this limit.

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, custom fabricated abutment (D6057) is limited to two procedure codes per 1 calendar year, and abutment supported porcelain/ceramic crown (D6058) is limited to two procedures codes per 1 calendar year. The record shows that you received two custom fabricated abutments (D6057 x2) and two abutment supported porcelain/ceramic crowns (D6058 x2) on February 8, 2021 and your custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2) and two abutment supported porcelain/ceramic crowns (D6058 x2) provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87631) provided on April 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.

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 87631 is "Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets".

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 services. Our reviewer says that the use of code 87631 is not supported by the records provided. Our reviewer found that the laboratory report documents more than 6 pathogens tested. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (87631) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on March 8, 2021.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that your original dentures were worn out and you would like to be reimbursed for these new dentures. The Plan denied your request. The Plan says these services are not covered under your plan.
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 complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on March 8, 2021.