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

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on July 27, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that or purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extractions (D7140) provided on December 17, 2020 by an out-of-network provider.
You asked the Plan to pay for the extractions. You say that you purchased the optional additional dental rider at the behest of an insurance agent. You say that you told them who your dentist was at the time and the agent told you that out-of-network services were covered at the same rate as in-network services. You say you had services with your preferred dentist over the summer, and the Plan denied coverage because the dentist is out-of-network. You then chose to terminate the optional dental rider because you felt it did not deliver what you were promised. The Plan denied your request. The Plan says this service is not covered by the mandatory supplemental dental benefit that comes with the Plan. The Plan states that your additional optional benefits were terminated on November 30, 2020, and these services would have been covered by the Plan if you had not removed the optional dental rider.
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 the mandatory benefit. In addition, these services were provided by an out-of-network provider, and out-of-network dental services are not covered under the mandatory or optional dental riders. Therefore, we decided that the Plan does not have to pay for multiple tooth extractions (D7140) provided on December 17, 2020 by an out-of-network provider.
You have a complaint about potential miscommunication from the Plan regarding out-of-network coverage for dental services under the optional dental rider. You say that an insurance agent told you that out-of-network dental services would be covered, but you say the Plan denied coverage for earlier services due to the
provider's out-of-network status. The Plan also states these services would have been covered under the additional rider in their decision letter. This complaint about possible misinformation 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 pay for the inpatient psychiatric services provided from November 16, 2019, to November 25, 2019.

You asked the Plan to pay for the inpatient psychiatric services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says rules for inpatient psychiatric services were not met.

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 psychiatric services. Our reviewer says that the requested care was not medically reasonable and necessary. Our physician reviewer found that this 59-year-old female was admitted to the acute inpatient psychiatric hospitalization on November 16, 2019. She did not have dangerousness to self or others, auditory or visual hallucinations or behaviors threatening acute safety. She was cooperative and compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others and did not have auditory or visual hallucinations. She was noted to be cooperative and compliant with treatment while not showing any acute threat to safety. 

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 psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided from November 16, 2019, to November 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the medical records
provided there is no documentation that the enrollee requires skilled nursing services. The enrollee does require
skilled therapy services; however, based on the medical records provided daily skilled services are not required.
This enrollee does not require the services on an inpatient basis, only 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 admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home injectable therapy rendered from October 9, 2020 to October 30, 2020.
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 S9542 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code S9542 (home injectable therapy) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the home injectable therapy rendered from October 9, 2020 to October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 00830) provided to the enrollee on June 17, 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 Current Procedural Terminology (CPT) code 00830-AA-P2 (67 unit) 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 00830 is "Anesthesia for hernia repairs in lower abdomen." We asked our coding 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 Our coding reviewer found the operative report documents "Anesthesia: General given by" the provider. However, no anesthesia report was included in documentation, and 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 services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (CPT 00830) provided to the enrollee on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092, R0070) provided on July 10, 2018.

You asked the Plan to pay for the transportation and set up of the portable x-ray. You say that you would like reconsideration because you have always been reimbursed for this service. The Plan denied your request. The Plan says the member was not in Skilled Nursing Facility as a result provider should bill POS 32 for the services to be covered.

The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of the portable x-ray. have not been met. Specifically, the claim was billed with place of service code 31, indicating that the member was in a Part A covered SNF stay. If the member is in a Part A stay, payment for these services are subject to consolidated billing. Additionally, the Plan has indicated that the member is not in a part A covered SNF stay so there is a more appropriate place of service code. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092, R0070) provided on July 10, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of the home oxygen system and the portable oxygen system services.

You asked the Plan to pre-approve continuation of the home oxygen system and the portable oxygen system services. You say that you still need the oxygen services. The Plan denied your request. The Plan says there is no documentation provided of the required laboratory or pulse oximetry confirming hypoxemia.

The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 

There is no recertification documentation. Therefore, we decided that the Plan does not have to pre-approve continuation of the home oxygen system and the portable oxygen system services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from May 10, 2021, forward.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our physician reviewer found the health plan's denial of continued inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized treatment plan, however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 10, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety. 

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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from May 10, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 7, 2021 by an out of network provider.
You asked the Plan to pay for the office visit. You say that the network provider could not provide the services needed. The Plan denied your request. The Plan says you did not request authorization to see this out-of-network physician.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 7, 2021 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 15, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 8, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that you are appealing to get the copayment back for the diabetic vision exam. 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each Medicare-covered medical eye exam.

You have been asked to pay a $20 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show a medical eye exam was billed due to your cataracts being checked. 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 eye exam provided on January 8, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), comprehensive periodontal evaluation (D0180), comprehensive oral evaluation (D0150) and vertical bitewings - 7 to 8 radiographic images (D0277) provided November 5, 2020.

You asked the Plan to pay for the full mouth debridement, periodontal exam, comprehensive oral exam, and vertical bitewing x-rays. You say that the services should be covered. The Plan denied your request. The Plan says the full mouth debridement and vertical bitewing x-rays are not covered under the enrollee's dental benefit and all the services were performed out-of-network and therefore are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal exams and comprehensive oral exams when provided by a network provider.

We looked at the file and Medicare rules. Full mouth debridement and vertical bitewing x-rays are not covered services under the enrollee's dental benefit. Additionally, the requested services were not provided by a network provider. Therefore, we decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), comprehensive periodontal evaluation (D0180), comprehensive oral evaluation (D0150) and vertical bitewings - 7 to 8 radiographic images (D0277) provided November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with a prosthodontist.
You asked the Plan to pre-approve a consultation with a prosthodontist. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 pre-approve a consultation with a prosthodontist.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a bi-level positive airway pressure (BiPAP) machine and supplies.

You asked the Plan to pre-approve BiPAP machine and supplies. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says that the denial of authorization for this device
is correct, because the records do not show that the enrollee's night breathing is severe enough to require a new
machine.

The Plan follows Medicare rules. Medicare rules state that PAP devices may be covered under certain
circumstances.

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 BiPAP machine and supplies. Our
reviewer says that the enrollee meets the Medicare criteria for the requested BiPAP. Our physician reviewer
found the record includes documentation of the enrollee's previous sleep studies, and that the enrollee continues
to benefit from BiPAP. The enrollee has met compliance requirements in the past. This is a replacement device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of BiPAP machine and supplies have been met. Therefore, we decided that the
Plan has to pre-approve a bi-level positive airway pressure (BiPAP) machine and supplies.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 81545) provided to the enrollee on August 4, 2020.
You asked the Plan to pay for the services. You say that there is medical evidence supporting this test. The Plan denied your request. The Plan says predictive genetic screening testing is not a Medicare benefit.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee'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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (CPT 81545) provided to the enrollee on August 4, 2020.