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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 22, 2021, to July 2, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act.
The Plan denied your request. The Plan says the enrollee has not received skilled care on the dates of service in
this case.
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 pay for the SNF care. Our reviewer says the enrollee
did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily
skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional
nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled
therapy on an inpatient basis in a SNF 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 the SNF care have not been met. Specifically, the file does not show that the
enrollee received daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled
nursing facility (SNF) care provided from June 22, 2021, to July 2, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on October 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the services (76705) provided on October 7, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) testing provided on July 15,
2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date
of service. The Plan denied your request. The Plan says the rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that a Computed Tomography Cerebral Perfusion Analysis (CTP) was provided. This testing is
medically reasonable and necessary in patients with acute ischemic stroke (AIS) caused by unilateral large
vessel occlusion. The records show that the testing was provided due to aphasia. Based on this information, the
Medicare rules for coverage have not been met.
The file shows that CPT code 70450 was billed with code 70496. We find that CPT code 70450 may be eligible
for payment when billed with this code pair. The claim does not show that the code at issue was billed with a
modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the
computed tomography (CT) testing provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the enrollee on July 27, 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 code has a status indicator of "B."
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 99100 is "Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 anesthesia services (procedure code 99100) provided to the enrollee on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99205) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you are asking for special circumstances to be considered. You would like to keep your local primary assignments because they are close to home. However, you need to not jeopardize any future treatment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the outpatient office visit (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from March 30, 2021, to April 1, 2021.

You asked the Plan to waive the copayment for inpatient hospital services. You say that you took your husband to the emergency room and the doctor on staff at the time ordered some images and then sent him home with instructions to follow up as soon as possible with the neurologist. You also say that the next day you noticed your husband was worse and called the ambulance, who took him back to the emergency room. You also say that this time, the provider ordered more tests, admitted him, and then transferred him to another hospital due to lack of beds. The Plan denied your request. The Plan says you were charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollee's must pay a $260 copayment for per day for days 1-7 of a hospital stay for plan members.

The enrollee has been asked to pay a $260 copayment for inpatient hospital services for two days of service, which is a total of $520 ($260 x 2 = $520). 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 when the enrollee enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from March 30, 2021, to April 1, 2021.

Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the colonoscopy and upper gastrointestinal endoscopy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the colonoscopy and upper gastrointestinal endoscopy. You say that you do not want to see this doctor because your doctor referred you after not being able to figure out what was wrong with you. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the colonoscopy and upper gastrointestinal endoscopy to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone (D7210) and bone replacement graft for ridge preservation (D7953), provided on August 5, 2021.

You asked the Plan to pay for the extractions and bone replacement graft. You say that you are being charged the wrong amount. The Plan denied your request. The Plan says the cost share was applied correctly to the extractions and the bone graft is not a covered service.

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. Specifically, the charged amount by the out-of-network provider for each extraction was $360.00, but the plan only pays 45% of the allowed amount of $162.00, which is $72.90 paid and $89.10 member responsibility. Also, anything above the allowable amount remains member financial responsibility ($360.00 - $162.00 = $198.00). Therefore, the total member responsibility for each extraction is $287.10 ($89.10 (55% coinsurance) + $198.00 (amount above the allowable) = $287.10. Additionally, the bone graft is not listed in the Plan's benefit chart, and therefore, is not a covered service. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone (D7210) and bone replacement graft for ridge preservation (D7953), provided on August 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for a psychotherapy visit provided on August 19, 2021.
You asked the Plan to pay for psychotherapy visit. You say that there was no adequate timeframe to obtain authorization for this service. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the provider did not make a documented attempt to consult the enrollee's primary care or attending physician.
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. The Plan denied payment on the basis that the provider did not make an attempt to consult the enrollee's primary care or attending physician prior to rendering service. However, that rule applies to psychology doctoral type providers. The rendering provider in this case is a Licensed Clinical Social Worker (LCSW); therefore, that coverage limitation does not apply. The Plan provided no other rationale or evidence to support a denial of payment for this service. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for a psychotherapy visit provided on August 19, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 25, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the place of service is inappropriate for the procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. We find that CPT code 99153 is a technical component only code. This means that this service is not payable.
We find that CPT code 99204 is not supported in the medical record. Specifically, the medical records provided do not include documentation of an office visit. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic footwear (CPT code L3250).
You asked the Plan to pre-approve the orthopedic footwear. You say that you cannot be fit with a prefabricated shoe because of your hemihyperplasia. The Plan denied your request. The Plan says this is not covered for your condition.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthopedic footwear have not been met. You do not have a diagnosis of diabetes or partial foot amputation. Therefore, we decided that the Plan does not have to pre-approve the orthopedic footwear (CPT code L3250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve voriconazole suspension 40MG/ML, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary due to bacterial
culture growth demonstrating candida krusei. The Plan denied your request. The Plan says the enrollee's health
plan does not cover outpatient prescription drugs; however, the enrollee may have a separate commercial
pharmacy benefit or Medicare Part D benefit managed by another carrier.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Voriconazole suspension 40MG/ML to be administered at home is not Medicare covered
under the Part A or B benefit. Therefore, we decided that the Plan does not have to pre-approve voriconazole
suspension 40MG/ML, for the enrollee.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 12, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician's services provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis C testing provided on September 1, 2021.
You asked the Plan to pay for the testing services. You say that your provider had no knowledge of this blood
test ever being done. The Plan denied your request. The Plan says you have exceeded the limits for testing.
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 file shows that you received Hepatitis C testing on September 1, 2021. You previously received this testing
in 2019. The records do not indicate that you are considered high risk. The services fall within the Hepatitis C
screening benefit category. Based on this information, we decided that the coverage rules have not been met.
Therefore, we decided that the Plan does not have to pay for the Hepatitis C testing provided on September 1,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency anesthesia service (99140) provided on July 15,
2021.
You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this code is always
bundled for payment and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that code 99140 is always bundled for payment.
We looked at the file and Medicare rules. This code is always bundled for payment and is not separately
payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been
met. Therefore, we decided that the Plan does not have to pay for emergency anesthesia service (99140)
provided on July 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing (SN) services of a registered nurse (RN) (G0299) and more than 28.5 hours per week of a home health aide (HHA) (G0156).
You asked the Plan to pre-approve the SN services of a RN and more than 28.5 hours per week of an HHA. The Plan denied your request. The Plan says the new allotted 28.5 hours of HHA per week appropriately meets your current needs. The Plan also says that while you require assistance with your activities of daily living (ADLs) and Instrumental Activities of Daily Living (IADLs) services, you do not meet the guidelines and regulations for HHA services.
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 SN services of a RN and more than 28.5 hours per week of a HHA. Our reviewer says that the requested home health skilled nursing services and accompanying home health aide services are not medically necessary or reasonable. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer found that the enrollee does not have documented skilled therapy needs. Our physician reviewer also found that the enrollee's care needs appear to be highly custodial. 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 SN services of a RN and more than 28.5 hours per week of a HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing (SN) services of a registered nurse (RN) (G0299) and more than 28.5 hours per week of a home health aide (HHA) (G0156).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 11, 2021.
You asked the Plan to pay for office visit. You say that this claim has not been paid at the appropriate rate. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because the
documentation does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a provider must furnish sufficient information to
the Plan to determine whether payment is due for a claim.
We looked at the file and Medicare rules. No records were submitted to support the service billed on this claim.
The Plan requested records, but none were submitted. Without supporting records, you have not furnished
sufficient information to the Plan to determine whether payment is due for this claim as it has been billed.
Based on this information, we decided that Medicare rules for coverage of office visit have not been met.
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 11, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing (81479) provided on April 22, 2021.
You asked the Plan to pay for genetic screening testing. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic screening 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 genetic screening testing (81479) provided on April 22, 2021.