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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need to be in the skilled nursing facility where you can get the occupational and physical therapy you need. The Plan denied your request. The Plan says the request for SNF care is not medically reasonable and necessary.
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 that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other daily skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary 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 skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 17, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of a nursing facility enrollee services coded 
99308 provided on March 29, 2021. 
 
You asked the Plan to pay for the supervision of a nursing facility enrollee services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99308 is supervision of a nursing facility patient (patient 
not present) requiring complex and multidisciplinary care modalities involving regular development and/or 
revision of care plans by that individual, review of subsequent reports of patient status, review of related 
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care 
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) 
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment 
plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more. 
 
We find that CPT code 99308 is not supported in the medical record. Specifically, this code has a status 
indicator of "B". A status indicator of B means that payment for this code is always bundled into payment for 
other services not specified and no separate payment can be made. Based on this information, we decided that 
Medicare rules for coverage of the supervision of a nursing facility enrollee services have not been met. 
Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility enrollee 
services coded 99308 provided on March 29, 2021.
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 SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 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 SNF care 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on May 15, 2021.
You asked the Plan to pay for an office visit. You say that the claim was billed correctly in this case. The Plan denied your request. The Plan says this service should be billed as an emergency room visit.
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 state that any physician seeing a
patient registered in the emergency department may use emergency department visit codes (for services
matching the code description). It is not required that the physician be assigned to the emergency department.
We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that this
service was provided in the emergency department and should be billed with an emergency department visit
code. Based on this information, we decided that Medicare rules for coverage of an office visit have not been
met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on May 15,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home
use (D9630) provided on March 25, 2021.
You asked the Plan to pay for the drugs or medicaments. You say that you told the hygienist that you did not
want any services that were not covered by your plan. The Plan denied your request. The Plan says this
procedure is not covered under your dental 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 drugs
or medicaments dispensed in the office for home use (D9630) provided on March 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 skilled nursing visits, 5 physical therapy visits (G0151), 1 occupational therapy visit, and 8 speech therapy visits.
You asked the Plan to pre-approve the home health services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the requested visits are not medically necessary.
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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the provided documentation does not show that you have skilled nursing needs. You do not have documented skilled therapy needs. The reviewer found that your needs appear to be custodial. Therefore, the reviewer found that the requested home health services are not medically necessary or reasonable. 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 home health services have not been met. Specifically, the file shows that you do not require skilled care. Therefore, we decided that the Plan does not have to pre-approve 2 skilled nursing visits, 5 physical therapy visits (G0151), 1 occupational therapy visit, and 8 speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two guided tissue regenerations (D4266 x2), osseous, osteoperiosteal, or cartilage graft (D7950), and bone replacement graft for ridge preservation (D7953) provided on May 11, 2021.
You asked the Plan to pay for the guided tissue regenerations, osseous, osteoperiosteal, or cartilage graft, and bone replacement graft. You say that these services were medically necessary, and you would like them to be reprocessed for payment. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 two guided tissue regenerations (D4266 x2), osseous, osteoperiosteal, or cartilage graft (D7950), and bone replacement graft for ridge preservation (D7953) provided on May 11, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services coded as 99283 provided on June 11, 2021.
You asked the Plan to pay for the emergency department services. You say that you would like this claim reprocessed based on the medical records provided. The Plan denied your request. The Plan says this claim was not billed with a modifier as required by Medicare rules.
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, we have confirmed that code 99283 has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services coded as 99283 provided on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported crown provided on June 24, 2021.
You asked the Plan to pay for the implant supported crown. You say that the brochure clearly states 50% of a
crown is covered for a preferred provider up to a maximum of $500. You say that the coverage does not state
exclusions to a crown, and you believe you would have partial coverage. The Plan denied your request. The
Plan says implant services 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, implant related services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant
supported crown provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 criteria for coverage 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 use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin three or 
more times per day.

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 continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits.
You asked the Plan to pre-approve the skilled nursing visits. You say that the medical records provided support
the necessity of the services in dispute. The Plan denied your request. The Plan says 3 visits have been
approved. The plan of care does not support the need for the 2 other visits.
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 skilled nursing visits. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee requires a monthly catheter change. Additional skilled nursing needs are
not documented. As such, the requested quantity/frequency of home health skilled nursing services is not
shown to be medically necessary or reasonable.
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 skilled nursing visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 2 home health skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided July 10, 2021.
You asked the Plan to pay for the ultrasound. 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. In this case, we have confirmed that code 76705 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76705) provided July 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on June 4, 2021.
You asked the Plan to pay for the refraction. You say that you were not aware of the charges or if the provider was a routine eye doctor. The Plan denied your request. The Plan says eye refractions are only covered if they are routine.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a refraction when it is received with a routine eye exam. 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 refraction have not been met. Specifically, the eye refraction was provided during a medical eye exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on June 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no services offered at a SNF that are not also offered at an inpatient rehabilitation facility.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented nursing or skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 enrollee needs therapy and the doctors have to monitor her to see if her condition worsens. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day for at least 5 days per week. While the enrollee may benefit from physical and/or occupational therapy, her needs can be met in an alternate low-intensity setting such as a skilled nursing facility or home health.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services provided on October 30, 2019.
You asked the Plan to pay for the emergency department services. You say that you do not have any timely filing guidelines. The Plan denied your request. The Plan says this claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency department services was not filed until March 9, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department services provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 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 were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 18, 2021.