Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Spinergy wheels and ZRA frame (K0108).
You asked the Plan to pre-approve the Spinergy wheels and ZRA frame. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Spinergy wheels and ZRA frame. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the evaluation that was performed did not state that the Spinergy wheels or ZRA frame were 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 Spinergy wheels and ZRA frame have not been met. Therefore, we decided that the Plan does not have to pre-approve the Spinergy wheels and ZRA frame (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission for a revision total knee arthroplasty for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs to be observed for 24 hours after the surgery. The Plan denied your request. The Plan says this procedure is not on the Inpatient Only list.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the total knee surgery may be safely performed with an observational 48 hour stay. Inpatient admission is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission for a revision total knee arthroplasty for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for physical therapy provided from March 31, 2021 
through May 3, 2021. 
 
You asked the Plan to reduce the cost for physical therapy. You say that the services were provided in the same 
manner as a previously claim that paid at a rate of $102. You say that the claims should be processed at the 
same rate and an additional check should be issued. The Plan denied your request. The Plan says the cost share 
applied correctly. 
 
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 your $750 deductible applies to physical therapy. Your contract with the Plan 
also says that you must pay 40% coinsurance for out-of-network physical therapy. 

The item or service you asked the Plan to reduce the cost for falls within the "Outpatient rehabilitation 
services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your 
$750 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy was received from March 31, 2021 to May 3, 2021. Therefore, 
$114.31 has been applied to meet your deductible. 
 
Since the $750 deductible was met, you have also been asked to pay $46.04, which is 40% of the allowed 
amount for the physical therapy. The allowed amount is $115.13 (40% x $115.13 = $46.04). 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 reduce the cost for physical therapy provided from March 31, 2021 through May 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on April 15, 2021.

You asked the Plan to pay for physical therapy services. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, PT services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home physical therapy (CPT code G0151) for
the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan
denied your request. The Plan says your request is not medically necessary because the enrollee's records show
the enrollee has completed their physical therapy and the enrollee has been discharged by the therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and
should be independent with a home exercise program. There is no documentation of a recent injury or decline
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the
enrollee's medical condition and therefore, 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 continued home physical therapy (CPT code G0151) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage (A0170).

You asked the Plan to pre-approve additional mileage. You say that you need additional mileage to get to a medical appointment. The Plan denied your request. The Plan says your benefit only allows 60 one-way trips with each one-way trip not exceeding 50 miles of driving distance.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 62 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage (A0170).
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 need IRF care, as you have multiple casts, cannot walk, and do not have anyone to help you at home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT Scan of the head (70450) provided on May 10, 2021.

You asked the Plan to pay for the CT Scan of the head. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request.

The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70496 and 70450.

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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. CPT code was billed by the same billing provider without a modifier to indicate that this service was distinct from CPT code 70496. 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 CT Scan of the head (70450) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical
x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis
(D1110), and topical application of fluoride varnish (D1206) provided on June 3, 2021.
You asked the Plan to pay for the dental services. You say that you did not realize the coverage for the dental
rider had been changed so drastically from the previous year. You also say that you would like these services to
be at least partially paid. The Plan denied your request. The Plan says you were not enrolled in the Platinum
Dental Rider on this date of service. The Plan also says that when you contacted the Plan on June 3, 2021
asking to enroll in the rider, you were advised enrollment could only be obtained during the first three months
of the Plan year.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation
(D0120), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), bitewing
x-rays (D0274), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on June 3,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Testosterone pellet 75 mg (S0189) provided March 18, 2021.
You asked the Plan to pay for Testosterone pellet. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. In this case, the code that has been billed has a status indicator of "I" and is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of Testosterone pellet have not been met. Therefore, we decided that the Plan does not have to pay for Testosterone pellet 75 mg (S0189) provided March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87798) provided on April 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 87798 is "Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism". We asked our coder 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 use of code 87798 is not supported by the records provided. Our reviewer found that the laboratory report documents more than 5 targets. There is a more appropriate code to report for this service, however the appropriate code for the services rendered is not covered by Medicare. We looked at this coder'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 the services (87798) provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on May 27, 2021.
You asked the Plan to waive the copay for the lab services. You say that the lab tests were done at your primary doctor's office. The Plan denied your request. The Plan says the claim processed 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 $40 copay for lab services in an outpatient hospital. The file shows the lab services were billed by an outpatient hospital facility. You have been asked to pay a $40 copay for the lab services. The labs fall within the outpatient diagnostic 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 copay for the lab services provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services (99212, 17000, 17003, 99213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON dermatology services. You say that you have been seeing the requested provider for years and do not want to see someone else. The Plan denied your request. The Plan says this care is available in-network and records were not received to support continuity of care.
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 dermatology services (99212, 17000, 17003, 99213) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on February 13, 2020, by an 
OON provider. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed for medical 
necessity. The Plan denied your request. The Plan says prior authorization was not obtained for services 
rendered by an OON provider. 

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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on February 13, 
2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ 
neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including 
substitutions, insertions, deletions, select rearrangements, and copy number variations (CPT code 0239U) 
provided to the enrollee on February 26, 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 services are not supported by the records. 
 
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 asked our coder 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 service. Our reviewer found targeted genomic sequence 
analysis panel was requested. The records provided, however, did not include progress notes or ordering 
physician documentation stating supportive information for this test such as why direct solid tumor testing is 
notjustify genetic testing. Therefore, this request for gene testing will be considered not medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 
311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select 
rearrangements, and copy number variations (CPT code 0239U) provided to the enrollee on February 26, 2021.  
available or if the enrollee accepted treatment including the expected chances of survival with treatment to
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral Dexamethasone (J8540) provided on April 7, 2021.
You asked the Plan to pay for the Dexamethasone. You say that this claim should have been paid. The Plan denied your request. The Plan says they could not determine if a physician's order was given, how the enrollee came to you, the referring provider, and/or whether the services are necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Dexamethasone have not been met. Therefore, we decided that the Plan does not have to pay
for the oral Dexamethasone (J8540) provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and additional intraoral x-ray (D0230) provided on April 14, 2021.
You asked the Plan to pay for the evaluation and x-ray. You say that this service should be covered because you last had this type of exam with a different dentist almost three years ago. You cannot afford these services. The Plan denied your request. The Plan says the frequency limitations for these services have been exceeded, and payment has been denied correctly.
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 can cover one intraoral x-ray every calendar year and one periodontal or comprehensive oral exam every three years. Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you had two intraoral x-rays on the date in question, one of which was covered by the Plan. Therefore, the second image exceeds the frequency limitation for this service. The Plan also provided documentation that you had a previous comprehensive oral exam in December 2019, which was covered by the Plan and was provided less than three years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and additional intraoral x-ray (D0230) provided on April 14, 2021.