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

We decided that the Plan does not have to pay for the drug test (CPT code G0482) provided to the enrollee on May 10, 2021, by out-of-network provider.
You asked the Plan to pay for the drug test. You say that you were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 drug test (CPT code G0482) provided to the
enrollee on May 10, 2021, by out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered for specific conditions. 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 a portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and a abutment supported crown (D6058).
You asked the Plan to pre-approve the dental services. You say that you need these services so that you can eat. The Plan denied your request. The Plan says custom fabricated abutment is not listed and therefore is not a covered service. The Plan says that abutment supported crown is not listed as a covered service either.
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 custom fabricated abutment and abutment supported crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and a abutment supported crown (D6058).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for microsurgical technique (69990) provided on April 5, 2021.
You asked the Plan to pay for 69990. You say that you received prior authorization for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is bundled and not separately payable.
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 69990 has a bundled relationship with code 22868 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for microsurgical technique (69990) provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this is a self-administered drug.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron for the
enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from January 1, 2021, to January 25, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you were told there would be no copayments due to the Coronavirus. The Plan denied your request. The Plan says copayments for Coronavirus treatment are only waived for inpatient hospital care. SNF services are not part of this waiver.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services. 

Records show that you were in the SNF for a total of 24 days. You were not charged a copayment for the first 20 days of this stay. For the last 4 days, you were charged a copayment of $184 per day, for a total of $736. According to your Evidence of Coverage, the Plan is only waiving cost sharing for inpatient hospital services related to the Coronavirus. The Plan is NOT waiving cost sharing for skilled nursing facility services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from January 1, 2021, to January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to provide the acute inpatient hospital care starting October 10, 2021.
You asked the Plan to provide acute inpatient hospital care. You say that inpatient hospital level of care is medically necessary, reasonable and appropriate. The Plan denied your request. The Plan says that under Medicare, the request is not medically necessary.
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 provide acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to provide the acute inpatient hospital care starting October 10, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Corus CAD testing (CPT code 81493) provided to the enrollee on July 22, 2020.
You asked the Plan to pre-approve the service. You say that the services were medically necessary. The Plan denied your request. The Plan says the manufacturer has failed to demonstrate that testing resulted in improved enrollee outcomes or that testing changed physician management to result in improved enrollee outcomes.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been shown that Corus coronary artery disease testing was medically reasonable and necessary for the enrollee in this case. There is insufficient evidence that the test results have clinical utility and result in improved patient outcomes. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Corus CAD testing (CPT code 81493) provided to the enrollee on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 20, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 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 physician services provided to the enrollee on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.
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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a knee orthosis is covered when specific criteria are met. 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 criteria for coverage are not met. Our physician reviewer found the submitted records do not show evidence that you have knee instability or excessive joint flexibility (joint laxity) on physical exam. There is no evidence of a recent surgery or injury to the knee. There is no evidence that you need the requested knee orthosis. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric bone growth stimulator.
You asked the Plan to pre-approve an electric bone growth stimulator. You say that an electric bone growth
stimulator is medically necessary. The Plan denied your request. The Plan says the medical records show only
seven months have passed since your surgery. Medicare criteria requires at least nine months for coverage.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for
failed fusion nine months after surgery. The medical records do not show you meet these criteria as it has not
been nine months since your surgery. Therefore, we decided that the Plan does not have to pre-approve an
electric bone growth stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical implant placements (D6010), prefabricated abutments (D6056) and abutment supported crowns (D6059) for teeth #13 and #14.
You asked the Plan to pre-approve the dental implant services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by the enrollee's dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical implant placements (D6010), prefabricated abutments (D6056) and abutment supported crowns (D6059) for teeth #13 and #14.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299).

You asked the Plan to pre-approve 4 home health skilled nursing visits. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have skilled nursing needs.

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 4 home health skilled nursing visits. Our reviewer says that the request home health care is not medically necessary. Our physician reviewer found the enrollee has been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. He does not require additional skilled nursing services at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home health skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grabber tool (E1399).
You asked the Plan to pre-approve a grabber tool. You say that you really need this reacher and your provider
suggested you get it. The Plan denied your request. The Plan says this item is not primarily used for a medical
purpose and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a grabber tool (E1399).
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 LTACH care is medically necessary.
The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does
not require transfer to LTACH.
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 that there is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis. 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 waive the copayment for inpatient mental health care provided from February 17, 2021, to March 2, 2021.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you disagree with the charges because you are unhappy with the care you received. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for days 1-4 for inpatient mental health care.
You received inpatient mental health care from February 17, 2021, to March 2, 2021. Therefore, you are responsible to pay a $395 copayment for days 1-4 (February 17, 2021, to February 20, 2021). $395 (copayment) x 4 (inpatient days) = $1,580. You have been asked to pay the total copayment amount of $1,580 for inpatient mental health care. Inpatient mental health care falls within the inpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient mental health care provided from February 17, 2021, to March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative treatment (D9110) provided on May 20, 2021.
You asked the Plan to pay for the palliative treatment (D9110). You say that a temporary filling was placed on your tooth so the doctor could clean out the infection. You say that the service should be covered. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative treatment (D9110) provided on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing (CPT code(s): 81401, 81403, 81404, 81405 and 81406) provided to the enrollee on February 8, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
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. Review of the file shows that the enrollee had genetic cardiovascular risk assessment testing on February 8, 2021. Medicare denies coverage for all cardiovascular genetic risk assessment panels for patients with suspected or documented cardiovascular disease. The test at issue in this appeal, the 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 cardiovascular genetic risk assessment testing (CPT code(s): 81401, 81403, 81404, 81405 and 81406) provided to the enrollee on February 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an ambulatory surgery center on June 15, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a preventive colonoscopy so there shouldn't be any cost. 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 $175 copayment for outpatient surgery at an ambulatory surgery center. The records show that the service you received was not a preventive screening colonoscopy. The records show that this colonoscopy was performed to evaluate your complaints of lower left quadrant abdominal pain and
chronic intermittent constipation. You have been asked to pay a $175 copayment for the diagnostic colonoscopy. A colonoscopy is only considered screening if it is performed in the absence of signs or symptoms of a medical problem. That was not the case here. Because you were being worked up for symptoms, it is a diagnostic colonoscopy. Diagnostic colonoscopies are surgical services, which is why it falls within the outpatient surgery at an ambulatory surgery center benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an ambulatory surgery center on June 15, 2021.