Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for wound care services provided at an
outpatient hospital facility from January 6, 2021, to March 3, 2021.
You asked the Plan to reduce the copayments for the wound care services. You say that your wife believed she
went to an office for each of these services, so only the $45 office visit copayment should apply. The Plan
denied your request. The Plan says these copayments were charged correctly. The Plan says that for each of the
four dates of service in question, the allowed amount for each is less than the enrollee's copayment obligation,
so she is responsible for the full allowed amount. The allowed amounts for each date of service are as follows:
For January 6, 2021, the allowed amount is $128.35; for January 20, 2021, the allowed amount is $373.83; for
February 3, 2021, the allowed amount is $373.83; and for March 3, 2021, the allowed amount is $128.35.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $395 copayment for outpatient hospital visits and non-surgical visits to an outpatient clinic.
The enrollee has been asked to pay a $395 copayment for each of the wound care services. The billing records
from these services show that the facility where these services were rendered is considered an outpatient
hospital facility and not an office setting. That is why the wound care services fall within the outpatient hospital
visits and non-surgical visits to an outpatient clinic benefit category. This means that the enrollee has been
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to reduce the copayments for wound care services provided at an outpatient hospital facility from January
6, 2021, to March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99221) provided on March 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is included in the global surgical payment.
The Plan must follow Medicare rules. Medicare rules say that Medicare approved amount for global surgical procedures includes payment for the services related to the surgery when furnished by the physician who performs the surgery. We looked at the file and Medicare rules. Payment for the requested service (99211) is included in the global surgical payment for the surgical services provided on February 12, 2021. Separate payment cannot be made for code 99211. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99221) provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 25, 2021.
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 this testing is unlikely to impact therapeutic decision making in the clinical management of patients.
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 this is considered screening testing and is unlikely to impact therapeutic decision-making. The review has determined that the laboratory services provided to the enrollee on March 25, 2021 were not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed". We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 22 or more drug classes were tested on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs more services because they have been through two (2) operations and need help with would care, etc. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of intestinal perforation which was complicated by an anastomotic leak and sepsis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.
You asked the Plan to pre-approve a lightweight wheelchair (K0003). You say that the enrollee needs a lightweight wheelchair. The Plan denied your request. The Plan says the records do not show you cannot self-propel a standard wheelchair in your home.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation on accomplishing your MRADLs, or if you can or cannot safely self-propel a standard manual wheelchair. Based on this information, we decided that Medicare rules for coverage of a lightweight wheelchair(K0003) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
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 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do 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 your 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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital admission.
You asked the Plan to pay for an inpatient hospital admission. You say that the medical records provided support the need for an inpatient hospital admission. The Plan denied your request. The Plan says the approved elective total hip arthroplasty can be provided in the outpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are met in this case.
Our physician reviewer found the record indicates that the enrollee is scheduled for a total hip arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac computed tomography angiography (CTA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has had chest pain located
in the center of his chest for six years. There is no documentation of an abnormal electrocardiogram (EKG) or
abnormal biomarkers. There is no history of a completed stress test. The CTA is therefore not reasonable or
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve cardiac computed tomography angiography (CTA).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that when applying for a Medicare provider number, a CP must submit to the carrier a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, contingent upon the patient's consent, the CP will attempt to consult with the patient's attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality. We looked at the file and Medicare rules. In this case, the documentation does not indicate that the psychologist is in contact with the PCP or attending, nor does the claim list a referring/ordering provider. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code(s): 81407, 81408) provided to the enrollee on March 17, 2021.
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit.
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, the laboratory testing, 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 laboratory testing (CPT code(s): 81407, 81408) provided to the enrollee on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bronchial thermoplasty procedure (31660, 31661).
You asked the Plan to pre-approve a bronchial thermoplasty. You say that the enrollee is an appropriate candidate for bronchial thermoplasty and this procedure will improve their overall quality of life. The Plan denied your request. The Plan says the requested service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a bronchial thermoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of asthma and also chronic obstructive pulmonary disease. Pulmonary function tests suggest restrictive disease rather than obstructive disease, and there is no bronchodilator challenge testing. FeNO levels are low, suggesting a diagnosis other than asthma, and the enrollee is severely obese. Patients with many of these co-morbidities were excluded from the clinical trials of bronchial thermoplasty for severe asthma. Therefore, the results of these trials do not necessarily apply to this enrollee. The denial is upheld.
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 bronchial thermoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a bronchial thermoplasty procedure (31660, 31661).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT code 81479) provided to the enrollee on February 9, 2021.
You asked the Plan to pay for the genetic testing. You say that the Cxbladder Triage test may be ordered on patients at an increased risk of bladder cancer to aid in the diagnosis of bladder cancer. The Plan denied your request. The Plan says these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.
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, the genetic testing, 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 genetic testing (CPT code 81479) provided to the enrollee on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crowns (D2740) for tooth # 27, core build up (D2950) for teeth # 27 and 30, and prefabricated post and core in addition to a crown (D2954) for tooth # 29 provided on May 26, 2021.
You asked the Plan to pay for the crown for tooth # 27, core build up and the prefabricated post and core in addition to a crown. You say that the teeth # 27, 29 and 30 are not able to be restored with traditional restorative materials due to lack of structural support from the remaining tooth structure. The Plan denied your request. The Plan says that the dental services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that a photocopy of an x-ray is not a reasonable substitution for the original diagnostic quality x-ray used by the Plan to make its decision. Additionally, we find that the Evidence of Coverage does not provide sufficient information to determine that the services would not be covered in this case. Therefore, we decided that the Plan has to pay for the crowns (D2740) for tooth # 27, core build up (D2950) for teeth # 27 and 30, and prefabricated post and core in addition to a crown (D2954) for tooth # 29 provided on May 26, 2021.
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 the lab services provided on January 28, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The file shows that the enrollee received comprehensive pharmacogenetic testing. The billed claim shows a place of service as an independent laboratory. The records do not indicate the specimen was obtained at the independent laboratory at issue in this case. Furthermore, if a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, shoulder (73030) provided May 20, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you disagree with the $15 copayment and request refund of $25 you had paid on your card. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $15 copayment for each x-ray service. You have been asked to pay $15 for the diagnostic service. The diagnostic service falls 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 the radiologic examination, shoulder (73030) provided May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the myocardial perfusion imaging provided on March 25,
2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion imaging is covered for the
indications established in the applicable LCD.
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 testing. Our reviewer says that the
requested myocardial perfusion imaging is not medically reasonable and necessary in this case. Our physician
reviewer found that the record indicates that the enrollee has an elevated calcium score. The record does not
indicate that the enrollee has angina or anginal equivalents. The record does not indicate that there is any
electrocardiogram abnormality. The record does not indicate the presence of any of the coverage indications.
The elements of the coverage criteria are not satisfied.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the myocardial perfusion imaging provided on March 25, 2021.