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

We decided that the Plan does not have to pay for genetic screening provided to the enrollee on August 10, 2020.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says this type of screening is not covered by Medicare.

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 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 genetic screening provided to the enrollee on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that the doctor shouldn't be penalized for the facility's failure to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan says that this patient was not receiving skilled services or inpatient care at this time.
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 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 medical services provided on June 12, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora second dual-energy X-ray absorptiometry (DXA) scan (77085) provided on August 21, 2020.You asked the Plan to pay fora second DXA scan. You say that the enrollee had multiple exams.The Plan denied your request. The Plan says only one unit is supported.The Plan must follow Medicare rules. Medicare rules say thatproviders must report the actual number of units provided for each procedure code.We find that 2 units of CPT code 77085 are not supported in the medical record. The medical record only supports 1 unit of CPT code 77085, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of a second DXA scan have not been met.Therefore, we decided that the Plan does not have to pay fora second dual-energy X-ray absorptiometry (DXA) scan (77085) provided on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora spinal fluid leak repair (63707-78) provided on May 25, 2020.You asked the Plan to pay fora spinal fluid leak repair. You say that this was billed correctly.The Plan denied your request. The Plan says the billed modifier is not appropriate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Wefind that the billing 63707-78 is not supported in the medical record. Specifically, modifier 78 is used to report an unplanned return to the operating or procedure room, by the same physician, following an initial procedure for a related procedure duringthe post-operative period. The record does not show that an initial procedure has been reported, and the medical records indicate that the previous procedure was performed by a different physician.Based on this information, we decided that Medicare rulesfor coverage of a spinal fluid leak repair have not been met.Therefore, we decided that the Plan does not have to pay fora spinal fluid leak repair (63707-78) provided on May 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this transfer is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 the enrollee is a 76-year-oldfemale who was admitted to the current acute care hospital with COVID-19 pneumonia and respiratory failure. She was treated with mechanical ventilation, tracheostomy, and PEG placement. She was treated for sepsis bacteremia with antibiotics and required chest tube. She was treated with steroids. Currently the enrolleestill is febrile and requires additional treatment to stabilize.The enrollee appears to require additional short-termacute care services which can safely be performed at the current facility. The enrollee does not require any services at the LTACH that are not already available at the current facility.There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.Therefore, this request for LTACH  services will be considered 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services you provided on May 19, 2020.
You asked the Plan to pay for the podiatry services. You say that your address changed so you did not receive this documentation from the Plan until several weeks later. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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. You are 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 podiatry services you provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on September 3, 2020.You asked the Plan to pay forthe dental service. You say that you did not receive an oral exam. You say that you went in to get your bite adjusted from the 3 fillings you received from another dentist. You say that that dentist could not see you for a couple of weeks. You say that you were in a lot of discomfort and no longer wish to see that provider.The Plan denied your request. The Plan says 1 limited oral evaluation is covered per calendar year. The Plan also says that the frequency limit 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, the frequency limit of 1 limited oral evaluation per calendar year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 29, 2020.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on February 13, 2020.You asked the Plan to pay forthe dental services. You say that you were advised to disregard thebill that you received, dated March 17, 2020. You say that you did not know that your dental plan had changed. You say that you are asking for an exception to coverage for these services. You also say that this provider was in network with the dental plan, to the best of your knowledge.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that dental services that you receive out of network 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.Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on February 13, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fortransport services provided to the enrollee on June 14, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says due to the enrollee'shospice election at the time of service, this claim should be submitted to Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay fortransport services provided to the enrollee on June 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveFreestyle Libre continuous glucose monitor (CGM).You asked the Planto pre-approvethe requested CGM. You say that you believe that this CGM is necessary for the enrollee.The Plandenied your request. The Plansayscriteria for the CGM are not met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrolleedoes not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the requested CGM have not been met.Therefore, we decided that the Plandoes not haveto pre-approveFreestyle Libre continuous glucose monitor (CGM)
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing care provided on July 27, 2020.You asked the Plan to pay for the initial nursing care. You say thatthe enrollee was not in hospice at the time of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-coverednon-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on July 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for initial nursing care provided on July 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. 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 forthe medical services provided on September 23, 2020 by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dialysis services you provided on February 3, 2020 to February 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe dialysis services. You say that you did not originally realize that this member had a Medicare Advantage plan, which is why you did not request authorization.  You said that because these services were medically necessary, they should be covered.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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.You are not a network provider with the Plan. The Plan had network providers available who could provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, wedecided that the Plan does not have to pay forthe dialysis services you provided on February 3, 2020 to February 24, 2020 by an out of network (OON) provider
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveKeytruda.You asked the Plan to pre-approveKeytruda. You say that this drug is medically necessary for this patient.The Plan denied your request. The Plan says that this drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the use of Keytruda is appropriate for this patient. Our physician reviewer found this patient is deemed CDDP (Cisplatin therapy) ineligible due to his age and comorbidities.  As a result, Keytruda is appropriate as a first line treatment for patients who are CDDP ineligible with bladder cancer per NCCN compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of Keytruda have been met.Therefore, we decided that the Plan has to pre-approveKeytruda.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 toopen the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these medically necessary services were provided in good faith.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. 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 forthe medical services provided on May 29, 2020 by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on July 24, 2020.

You asked the Plan to waive the copayment for lab tests. You say that these preventive care services require no copayment according to your Plan guide. The Plan denied your request. The Plan says the copayment amount you are 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). Your contract with the Plan clearly says that you must pay $25 copayment for lab tests. 

You have been asked to pay $25 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory testing provided on July 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services rendered from September 5, 2019 to October 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was bed-bound and totally dependent for transfers and activities of daily living. The therapy notes indicate that she was not appropriate for skilled treatment due to her lack of ability to participate and poor rehabilitation potential. No skilled nursing needs were documented. She did not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services rendered from September 5, 2019 to October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis, LT, RT (L3916) provided July 8, 2020 to July 9, 2020.You asked the Plan to pay forthe orthoses. You say that the enrollee should not be required to see a specific physician historically and previously as a benchmark for provided pain management. Please review the attached documentation.The Plandenied your request. The Plan says the supporting documentation does not match the information sent on the claim. Claim lacks information or has submission/billing errors.The Plan must follow Medicare rules. The rules state that DMEPOS is covered onlywhen there are both a physician order and proof of delivery. In this case, we find that the billed service is not supported in the medical records. There were no claims from the ordering/referring physician within the last 6 months prior to the date of service. Therefore, without a face-to-face encounter, the ordering physician could not gather the information associated with diagnosing, treating or managing the clinical condition for which the orthoses were ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthosis, LT, RT (L3916) provided July 8, 2020 to July 9, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe occupational therapy services provided from August 4, 2020 to August 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe occupational therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe occupational therapy services provided from August 4, 2020 to August 27, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided from October 16, 2019, to October 18, 2019.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you cannot pay this copayment.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 $320 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay a $320 copayment per day for days 1-5 for the inpatient hospital services. The inpatient hospital services fallwithin the inpatient hospital care benefit category. This means that you have been askedto 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 forthe inpatient hospital services provided from October 16, 2019, to October 18, 2019