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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.

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 the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
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 requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet
criteria. 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 the enrollee received oral medications and has
stable vital signs. Her lungs were clear. The enrollee does not meet severity of illness or intensity of service
criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT
code 81442) provided to the enrollee on May 27, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the document does not indicate how the test results will assist in managing the enrollee's
condition nor does the claims system support the enrollee was seen by the physician on the lab order requisition
prior to the test being ordered.
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 service, 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
cardiac risk assessment genetic screening testing (CPT code 81442) provided to the enrollee on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s)
(eg, anesthetic (CPT code 62323), for the enrollee.
You asked the Plan to pre-approve the injection. You say that the requested service is medically necessary. The
Plan denied your request. The Plan says the requested service does not meet the criteria for 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 pre-approve the injection. Our physician reviewer
found there is no documentation of the enrollee's duration of pain (of at least 4 weeks) and no documentation
that the enrollee failed a 4-week trial of non-invasive/conservative treatment. In addition, there is no
documentation of radicular pain severe enough to greatly impact the quality of the enrollee's function or life.
An objective pain scale or functional assessment has not been documented. The review has determined that the
ESI is 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 injection have not been met.
Therefore, we decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic
substance(s) (eg, anesthetic (CPT code 62323), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for SNF care is correct.
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 the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a skilled nursing facility (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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (billed with procedure
codes E0673 and E0675) provided on July 21, 2021.
You asked the Plan to pay for the pneumatic compression device. You say that this device is necessary for the
prevention of deep vein thrombosis. The Plan denied your request. The Plan says this item is not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device that provides
intermittent limb compression for the purpose of prevention on venous thromboembolism is a preventive
service. Items that are used for a preventative service or function are excluded from coverage under the
Medicare Durable Medical Equipment benefit. According to the case file and your appeal letter, the pneumatic
compression device you provided was ordered solely to prevent deep vein thrombosis. Medicare does not
cover compression devices for preventive reasons. We looked at the file and Medicare rules Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device
have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression
device (billed with procedure codes E0673 and E0675) provided on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided on July 29, 2021.  You asked the Plan to pay for the medical services. You say that You did not provide an argument for coverage. The Plan denied your request. The Plan says this claim was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of M are not payable under the Outpatient Prospective Payment System (OPPS).  In this case, you billed only two codes: 93000 and G0463.  You billed these codes on an OPPS claim.  Code 93000 has a status indicator of M, meaning that it is not payable under OPPS.  As a result, the claim for these services cannot be processed because of this coding error.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay the initial observation care (99220). We decided that the Plan does not
have to pay the services provided between 10:00 PM and 8:00 AM at 24-hour facility.
You asked the Plan to pay the initial observation care (99220). You say that you would like reconsideration
based on the records submitted. The Plan says that CPT code 99053 has a status indicator of B.
We decided that the Plan has to pay the initial observation care.
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent
efforts to gather and forward information to the Independent Review Entity (IRE).
We looked at your request, the file and Medicare rules. Based on this information we have determined that
Medicare criteria for coverage have been met. Specifically, the Plan has not forwarded any evidence as to why
this service was denied. It is the burden of the Health Plan to substantiate their denial with evidence. In this
case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the
Plan has to pay the initial observation care.
We also decided that the Plan does not have to pay the services provided between 10:00 PM and 8:00
AM at 24-hour facility.
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly.
We looked at your request, the file and Medicare rules. Based on this information we have determined that
Medicare criteria for coverage have not been met. Specifically, CPT code 99053 has a status indicator of B.
This means that the payment for CPT code 99053 is always bundled into the payment for another service or
procedure. Separate payment is not made. Therefore, we decided that the Plan does not have to pay the services
provided between 10:00 PM and 8:00 AM at 24-hour facility.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the oxygen supplies you received from November 30, 2020, to November 30, 2021.  You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you do not believe you should have to pay this because you thought insurance covered it. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment.   You have been asked to pay 20% coinsurance for the oxygen supplies. The oxygen supplies fall within the durable medical equipment 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 coinsurance for the oxygen supplies you received from November 30, 2020, to November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), intravenous
moderate conscious sedation, first 15 minutes (D9239) and intravenous moderate conscious sedation, each
subsequent 15-minute increment (D9243) provided on June 7, 2021.
You asked the Plan to pre-approve a comprehensive oral evaluation and intravenous moderate conscious
sedation. You say that the enrollee has advanced rheumatoid arthritis, osteoarthritis and neuropathy. The
enrollee's dentist advised her to have the services done under sedation because she would not be able to hold
her mouth open, and her body would not be able to handle the pain with local anesthesia. The Plan denied your
request. The Plan says the sedation does not qualify for benefits. The Plan also says that you have exceeded the
frequency limitation for a comprehensive oral exam. 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.
We looked at the file and Medicare rules. The records show that you received an oral evaluation on February 2,
2021 and March 18, 2021, therefore, you have exhausted your maximum benefit for this service. The records
also show that you did not have complex surgical dental services, therefore, the sedation does not qualify for
benefits. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral
evaluation and intravenous moderate conscious sedation have not been met. Therefore, we decided that the
Plan does not have to pre-approve a comprehensive oral evaluation (D0150), intravenous moderate conscious
sedation, first 15 minutes (D9239) and intravenous moderate conscious sedation, each subsequent 15-minute
increment (D9243) provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing (81241, 81291, 81328, 81355,
81401, 81479, 0031U, 0032U, 81225, 81226, 81227, 81230, 81240 and 81231) provided on December 9, 2020. You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says this claim was billed with an
inappropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pharmacogenomic testing have not been met. Specifically, this claim was billed with the
laboratory POS code while the records indicate that the member's face-to-face service was rendered in an office
setting. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing (81241,
81291, 81328, 81355, 81401, 81479, 0031U, 0032U, 81225, 81226, 81227, 81230, 81240 and 81231) provided
on December 9, 2020
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the Cologuard test (procedure code 81528) provided on date of service June 2, 2021.  You asked the Plan to pay for the Cologuard test. You say that Medicare has been covering this test for years. The Plan denied your request. The Plan says that this screening test is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that effective for dates of service on or after October 9, 2014, colorectal cancer screening using the Cologuard test (code 81528) is covered once every 3 years for asymptomatic Medicare beneficiaries who are 50-80 years of age and are at average risk for developing colorectal cancer. As such, this is a coverable screening test and it appears that this was billed correctly.  The Plan has not provided a valid argument for non-coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cologuard test have been met. Therefore, we decided that the Plan has to pay for the Cologuard test (procedure code 81528) provided on date of service June 2, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the take home drugs (D9630 x 2), scaling and root planing (D4341 x 4), partial lower denture (D5226), unspecified adjunctive service (D9999), extraction (D7140), and crown (D2740) provided on June 23, 2021.  You asked the Plan to pay for the dental services provided on June 23, 2021. You say that you have sent in all of the information that you have. The Plan denied your request. The Plan says the maximum reimbursement amount has already been provided.  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 maximum reimbursement amount of $1,000 has been exhausted. The record shows that the Plan paid $981.75 for the partial upper denture you received on August 17, 2021, and $18.27 toward the services you received on June 23, 2021. $981.75 + $18.25 = $1,000. Therefore, we decided that the Plan does not have to pay for the take home drugs (D9630 x 2), scaling and root planing (D4341 x 4), partial lower denture (D5226), unspecified adjunctive service (D9999), extraction (D7140), and crown (D2740) provided on June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zarxio.  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 part of a clinical trial and not covered.  The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.  In this case, you asked the Plan to pre-approve these services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the
enrollee. The Plan denied your request. The Plan says drugs dispensed by a pharmacy are not covered by
Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Prolia (J0897). Benefits for Prolia 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: SNF
Decision: Partially Favorable

We decided that the Plan has to waive $552 of the copayment charged for the SNF services. We decided that
the Plan does not have to waive the remaining $1104 of the copayment for these services.
You asked the Plan to waive the copayment for the SNF services. You say that you do not believe the Plan has
calculated the accumulated dates of your stay correctly. The Plan says that you were charged this cost sharing
correctly.
We decided that the Plan has to waive $552 of the copayment charged for these SNF services.
Medicare rules state that Plans must clearly disclose cost sharing amounts to their enrollees. In this case, your
Evidence of Coverage says that you pay a $0 copayment for days 1-20 and a $184 copayment per day for days
21-100 for skilled nursing facility services. A benefit period is the way the Plan measures your use of skilled
nursing facility services. A benefit period begins the day you to into a skilled nursing facility and ends when
you haven't received skilled nursing facility care for 60 days in a row.
Records show that you were in a SNF from April 27, 2021, to July 28, 2021. These dates of service are not in
dispute in this current appeal. According to your contract, you do not owe a copayment for the first 20 days of
SNF care. The first 20 days of SNF care occurred during your previous SNF stays. Because you were not out
of the SNF for 60 days or more, the stay from August 1, 2021, to August 6, 2021, is within the same benefit
period. That means that the $184 copayment per day is applicable to these dates of service. This is a six-day
span. According to your contract, you pay a $184 copayment per day, for a total of $1104 ($184 x 6 = $1104).
This is the copayment that the Plan should have charged you for this SNF stay. However, according to the bills
that the Plan provided in the case file, they are instead charging you $1656 for this stay. This is an excess
charge of $552 that the Plan has not accounted for in the case file documentation submitted. Therefore, the
Plan does not have to waive $1104 of the copayment, but the Plan must waive the remaining $552 of the
copayment charged for the SNF stay you had from August 1, 2021, to August 6, 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.