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

 We decided that the Plan does not have to pay for the triiodothyronine T3 assay coded 84480, the general health panel coded 80050, and the ferritin assay coded 82728 provided on October 8, 2020.  You asked the Plan to pay for the triiodothyronine T3 assay, the general health panel, and the ferritin assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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.  In this case, we have confirmed that code 84480 is a column II code to column I code 84481. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 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 the triiodothyronine T3 assay coded 84480, the general health panel coded 80050, and the ferritin assay coded 82728 provided on October 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services rendered from July 10, 2021, to July 15, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim to be reprocessed for payment. 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 enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 9, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services rendered from July 10, 2021, to July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a surgical boot provided on October 8, 2021.  You asked the Plan to pay for a surgical boot. You say that you provided services based on the order. The Plan denied your request. The Plan says prior authorization was not requested.  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 a surgical boot provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on September 30, 2021.  

You asked the Plan to pay for the bitewing x-ray. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period for the procedure grouping.  

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, bitewing x-rays are limited to one of either codes D0270, D0272, D0273, D0274, or D0277 once per plan year. The record shows that you received bitewing x-rays (D0274) on March 19, 2021, and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0270) provided on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021. 

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on March 16, 2021.  

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 the services are not covered.  

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  

The test at issue in this appeal, GeneSight, 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 the GeneSight testing rendered on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation and management services provided on August 31, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the evaluation and management services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  

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 the evaluation and management services provided on August 31, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on August 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that you rely on the facility to obtain this precertification or authorization when they ask you to see patients in their location. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also states that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a domiciliary or rest home visit (99335) provided on August 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 13, 2021.  You asked the Plan to pay for the dental service. You say that your previous provider did not treat you with respect. You also say that the new one did and therefore should be paid instead. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan 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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on September 8, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 8, 2021.  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 this claim was not billed with the appropriate place of service code.  The Plan must follow Medicare rules. Medicare rules say that for 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, this claim was billed with the laboratory place of service code while the records indicate that 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 June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for hereditary cardiac assessment testing provided on May 20, 2021.  You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was performed for screening purposes which 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 in the Medicare rules section, are not covered.  The test at issue in this appeal, genetic testing, was solely for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiac assessment testing provided on May 20, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient hospital discharge care services (99217) provided on May 11, 2021.  You asked the Plan to pay for code 99217. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. The rules also say that when a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care, from CPT code range 99218 - 99220, and CPT observation care discharge CPT code 99217.  We looked at the file and Medicare rules. In this case, the medical documentation indicates that the enrollee entered observation care on May 10, 2021 and was discharged on May 11, 2021. There is no documentation provided that the appropriate qualifying initial observation care procedure code was billed. Without this code, the observation care discharge day management coded as 99217 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the outpatient hospital discharge care services (99217) provided on May 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services (97110) provided on January 27, 2021.  You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services (97110) provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 22, 2021.  

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.    

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 22, 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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.  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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure, anemia and gastrointestinal bleeding. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 power wheelchair with accessories.  You asked the Plan to pre-approve a group 2 power wheelchair with accessories. You say that you can only walk so far due to the damage in your lungs. The Plan denied your request. The Plan says a group 2 power wheelchair is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a group 2 power wheelchair with accessories. Our reviewer says that while you may have the cognition to safely operate the requested wheelchair, the documentation does not support that the wheelchair is medically necessary. The documentation does not reveal an updated home assessment to support that the requested device will be able to safely maneuver in the home and access rooms. The home assessment is from 2016 and while the address appears the same as your current address, it is not clear whether there have been home modifications or considering physical layout, doorway width, doorway thresholds, and surfaces particularly for the bathroom which is noted to be 23 inches. The documentation does not support that the wheelchair will significantly improve your ability to participate in MRADLs in the home.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 power wheelchair with accessories have not been met. The documentation does not support that the wheelchair will significantly improve your ability to participate in MRADLs in the home. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the standard wheelchair and related services purchased December 23, 2020, from provider not contracted with Medicare.  You asked the Plan to pay for the wheelchair and related services. You say that this equipment was medically necessary for your condition. The Plan denied your request. The Plan says prior authorization was not obtained before this equipment was purchased from an out-of-network (OON) provider.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the standard wheelchair and related services purchased December 23, 2020, from provider not contracted with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic care (G0283, 99202, 97012) provided July 23, 2021.  You asked the Plan to pay for the chiropractic care. You say that the services were medically necessary. The Plan denied your request. The Plan says the chiropractic services performed are non-covered.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine to correct a subluxation. Therefore, we decided that the Plan does not have to pay for chiropractic care (G0283, 99202, 97012) provided July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Lite test strips.  You asked the Plan to pre-approve Freestyle Lite test strips. You say that these are necessary for you. The Plan denied your request. The Plan says that the prescriber did not provide a supporting statement.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if criteria are met in this case. Based on this information, we decided that Medicare rules for coverage of Freestyle Lite test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer for the enrollee.  You asked the Plan to pre-approve Injectafer. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.  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 Injectafer. Our reviewer says that Injectafer is not medically reasonable and necessary for the enrollee. In this case, the patient has not tried and failed Ferrlecit (sodium ferric gluconate), Infed, or Venofer. 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. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Injectafer.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer for the enrollee.