Persius/hicric huggingface dataset:
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 you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the IRF services.
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 there are no complex nursing or rehabilitation needs.
The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this member 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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from May 27, 2021, to June 25, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you were told that this entire bill would be covered. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services. Records show that you were in the SNF for 29 days. You were not charged a copayment for the first 20 days. For the remaining 9 days, you were charged a $184 copayment per day for a total of $1656. You have been asked to pay a $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for the SNF services. 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 skilled nursing facility (SNF) services you
received from May 27, 2021, to June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) initial acupuncture, initial 15-minute (97810) provided June 24, 2021 to July 22, 2021.
You asked the Plan to pay for the acupuncture services. You say that please see attached claims and forms for reimbursement. The Plan denied your request. The Plan says this is not a covered benefit because the records show that these two acupuncture visits were not for the treatment of chronic low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were not for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) initial acupuncture, initial 15-minute (97810) provided June 24, 2021 to July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and cleaning (D1110) provided on September 7, 2021.
You asked the Plan to pay for the dental services. You say that you used an in-network provider and received covered services and feel this claim should be paid. The Plan denied your request. The Plan says you previously disenrolled from the optional dental rider and have had over $240 worth of preventative dental care this year. The mandatory dental rider covers a maximum of $240 for covered dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of $240 for preventative dental care per calendar year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services provided exceeded the Plan's maximum allowance for supplemental preventative dental care for 2021.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and cleaning (D1110) provided on September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on
You asked the Plan to waive the copayment for the MRI. You say that the doctor requested this test before he would see you. You said that the doctor's office told you that this would be covered. The Plan denied your request. The Plan says this claim was not denied, rather, you were charged the applicable copayment. The Plan says that because the allowed amount for this service ($223.08) is less than your copayment obligation, you are responsible for the full allowed amount.
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 $250 copayment for diagnostic radiology services.
You have been asked to pay a $250 copayment for the MRI. The MRI falls within the diagnostic radiology services 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 magnetic resonance imaging (MRI) of the spine you had on
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care and debridement rendered on June 26, 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 must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT codes 11042, 11043, 11044, and 99309 is 1. The MAI value for these codes is 2. You billed 2 units of each code, exceeding the MUE. 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 for the nursing facility care and debridement rendered on June 26, 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 you would like reconsideration because the
requested IRF services are medically necessary. The Plan denied your request. The Plan says the member does
not meet Medicare criteria for coverage of the IRF services.
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 there are no complex nursing or rehabilitation needs.
The member does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive
rehabilitation program. There is not a reasonable expectation that this member 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry rendered on July 3, 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 procedure code 88360 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 88360 (tumor immunohistochemistry) and 88341 (immunohistochemistry, per specimen). Code 88341 is a column II code with a modifier indicator of 1 when billed with column I code 88360. The Plan paid column II code 88341 and cannot pay column I code 88360. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry rendered on July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on August 19, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on August 19, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) provided to the enrollee on July 28, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this was provided by an un-approved provider.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 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 medically reasonable or necessary. Our physician reviewer found you are requesting reimbursement of the cost of purchase of a portable oxygen concentrator (POC). You indicate that you have chronic obstructive pulmonary disease (COPD). There are no medical records provided to establish the medical necessity of this item. Specifically, there are no measurements of oxygen levels during activity, or at rest, to support a need for supplemental oxygen. There is no physician documentation of the reasons that a POC is necessary. No information is provided about whether you have been supplied with other forms of portable oxygen. This is therefore 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 services have not been met. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) provided to the enrollee on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (20704) provided on March 21, 2021.
You asked the Plan to pay for code 20704. 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. In this case, we have confirmed that code 20704 is an add-on code and has not been billed with an appropriate primary procedure code. 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 surgical services (20704) provided on March 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on July 26, 2021.
You asked the Plan to pay for the hot or cold pack therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says no separate payment is made for CPT code 97010.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 97010 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 97010 has a status indicator of B. This means that payment for this service is always bundled into the payment for another service. Based on this information, we decided that Medicare rules for coverage of the hot or cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), bone replacement graft (D7953), fixed partial denture sectioning (D9120) and sales tax (D9985) provided on August 4, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 surgical extraction (D7210), bone replacement graft (D7953), fixed partial denture sectioning (D9120) and sales tax (D9985) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDX testing provided on July 21, 2021.
You asked the Plan to pay for the ConfirmMDX testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no documentation that the member was being considered for a repeat biopsy due to persistent or elevated cancer-risk factors from the time of initial biopsy.
The Plan follows Medicare rules. Medicare rules say that ConfirmMDX is covered when the previous negative prostate biopsy must have collected a minimum of 8 tissue cores and when a minimum tissue volume criteria of 20 microns of prostate biopsy core tissue is available. 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 ConfirmMDX testing. Our reviewer says that the member does not meet LCD criteria for coverage of the ConfirmMDX testing. Our physician reviewer found the member does not have 8 cores with a minimal volume of 20 microns. The record shows that the member only has 3 meeting this requirement. 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 ConfirmMDX testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDX testing provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on July 2, 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 genetic testing not related to pregnancy requires prior authorization.
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 the enrollee treating physician is interested in changing medications. Unfortunately, genetic testing has not yet been shown in high quality studies to show significantly improved outcomes by using this testing compared to standard medication selection and trial to support its general use for this clinical scenario. Therefore, the GeneSight Psychotropic gene testing will be considered not medically necessary at this time. 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 genetic testing services provided to the enrollee on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement services you received at an outpatient hospital facility from March 25, 2021, to June 30, 2021.
You asked the Plan to waive the copayment for the wound debridement services. You say that you did not have these services at a hospital. You said that you had these services at a wound care clinic, so these charges are in error. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan contacted the provider and the provider confirmed that the facility that performed these services bills as an outpatient hospital facility.
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 $250 copayment for surgery or other services at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the wound debridement services. the wound debridement services fall within the surgery or other services at an outpatient hospital facility 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 wound debridement services you received at an outpatient hospital facility from March 25, 2021, to June 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 22, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows that the services were not rendered by a Medicare-certified provider. The file shows that the provider is an institutional provider. 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 for the emergency room (ER) services rendered on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to out-of-network ophthalmology services you received on June 25, 2021.
You asked the Plan to waive the deductible applied to the out-of-network ophthalmology services. You say that this is a service that is covered by Medicare. The Plan denied your request. The Plan says you had not met your deductible at the time you received these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible which applies to out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network ophthalmology services was received on June 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied to out-of-network ophthalmology services you received on June 25, 2021.
Your complaint about the Plan's failure to coordinate your benefits with other insurance is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints