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

We decided that the Plan does not have to waive the copayment for the skin lesion removal procedure you had
at a dermatologist's office on April 27, 2021.
You asked the Plan to waive the copayment for the dermatology services. You say that the office didn't know
for sure if the doctor had gotten all of the pre-cancer on March 31, 2021, so they called you to come back. You
do not think you should have to pay this copayment. The Plan denied your request. The Plan says you were
charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for specialist services.
You have been asked to pay a $35 copayment for the dermatology services. The specialist copayment applies
each time you see the specialist, regardless of the reason. 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 skin lesion removal procedure you had at a dermatologist's office on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiography report (93042) provided on
February 25, 2021.
You asked the Plan to pay for the rhythm electrocardiography report. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says there is an edit
that exists between CPT code 93042 and 99291.
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 93042 is rhythm ECG, 1-3 leads; interpretation and
report only.
We find that CPT code 93042 is not supported in the record. Specifically, CPT code 90342 is a column II code
to CPT code 99291 which has been approved by the Plan. CPT code 90342 is not eligible for separate
reimbursement in this case. Based on this information, we decided that Medicare rules for coverage of the
rhythm electrocardiography report have not been met. Therefore, we decided that the Plan does not have to pay
for the rhythm electrocardiography report (93042) provided on February 25,2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your
records do not show that you require daily skilled services that can only be provided on an inpatient basis. The
Plan states the services you require, such as additional therapy services, can safely be received at a different
setting, for example, home with home health, in residential care, or home with close follow-up with your
doctor.
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 have stabilized medically and are ready
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily
basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although
further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent
skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication;
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute
exacerbations of chronic medical problems. Your physical function is at or near their baseline and the enrollee
can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastric banding procedure (StomaphyX) and inpatient
hospital admission.
You asked the Plan to pre-approve these services. You say that this procedure will allow you to lose weight.
The Plan denied your request. The Plan says that your records show that the procedure that you have requested
is similar to a vertical gastric banding procedure which is not covered by Medicare.
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 requested services are not considered medically reasonable and necessary in this case. The record indicates
that you have previously undergone bariatric surgery and have regained weight due to excessive caloric intake.
The record provided does not establish the medical necessity and reasonableness. Our physician reviewer found
that your condition does not meet criteria for these services.
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 a gastric banding procedure (StomaphyX) and inpatient hospital admission
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider
from June 22, 2020, to May 26, 2021.
You asked the Plan to pay for the services. You say that the services were emergent. The Plan denied your
request. The Plan says the office visits were not emergent.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided to you by an out-of-network provider from
June 22, 2020, to May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on May 25, 2021.

You asked the Plan to pay for GeneSight Psychotropic testing. You say that this is a covered service. The Plan denied your request. The Plan says this testing is not supported.

The Plan must follow Medicare rules. Medicare rules say that in order for any Pharmacogenomics services to be covered, the patient's medical record must clearly reflect that the criteria for coverage have been met. The rules also say 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. Although the order form indicates that the criteria for coverage are met, no medical records from the ordering physician have been submitted to verify this information. Based on this information, we decided that Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88342) rendered by the out-of-
network (OON) provider on March 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (88342) rendered by the out-of-network (OON) provider on
March 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN in the home health or hospice setting, each 15 minutes (CPT code G0299 X 3), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the records show that four (4) nursing visits have previously been approved to help the
enrollee. The Plan states the enrollee's vital signs, taken by the home health nurse, are stable, the enrollee has caregivers available to help manage their treatment as needed, the enrollee does not have any wounds that require nursing care, and the records do not support the need for a skilled nurse to make more 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 services. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 pre-approve direct skilled nursing services of a RN in the home health or hospice setting, each 15 minutes (CPT code G0299 X 3), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that the item is 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. 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 the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle
Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre 14-day sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroid stimulating agent (84443) and vitamin D testing
(82306) provided on June 21, 2021.
You asked the Plan to pay for the thyroid stimulating agent and vitamin D testing. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are
not covered by Medicare as a screening tool.
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 thyroid stimulating agent and vitamin D 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 thyroid stimulating agent (84443) and vitamin D testing (82306) provided
on June 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be stable and has nearly reached maximal medical improvement from an acute care standpoint. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: in the long term acute
care hospital, skilled nursing facility, or home with home health 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 the enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of
rehabilitative services with regular physician evaluation. The enrollee is limited by his weight bearing
restriction. The enrollee's care needs can be met at a lower level of care, such as skilled nursing facility.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 10, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth consultation (G0426) rendered by the out-of-
network (OON) provider on July 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the telehealth consultation (G0426) rendered by the out-of-network (OON) provider
on July 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair.
You asked the Plan to pre-approve the group 3 power wheelchair. You say that you would like reconsideration because the requested wheelchair is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the requested wheelchair.
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. 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 group 3 power wheelchair. Our reviewer says that you do not meet criteria for base code power wheelchair group 3. Our physician reviewer found you do not have a neurological condition, myopathy or congenital skeletal deformity which is causing mobility impairment for which a Group 3 power wheelchair is reasonable and 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 group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3 power wheelchair
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower teeth extraction with alveoloplasty to be provided
by an out-of-network (OON) provider.
You asked the Plan to pre-approve lower teeth extraction with alveoloplasty to be provided by an OON
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
lower teeth extraction with alveoloplasty to be provided by an out-of-network (OON) provider.