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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs may be met in a lower level of care.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on April 9, 2021.
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says this request is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, is included in the fee schedule payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81001) provided on February 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that the laboratory does not receive patient information prior to rendering services. The Plan denied your request. The Plan says the enrollee was referred to this laboratory by an out-of-network 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 laboratory services (81001) provided on February 12, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0480) provided on July 15, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (G0480) provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 26, 2021 to June 15, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that medical necessity appeal based on medical literature that substantiates the efficacy of the treatment rendered. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided May 26, 2021 to June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing provided on July 21, 2021.
You asked the Plan to pay for CxBladder testing. You say that this testing provides essential diagnostic and treatment planning information. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare has affirmed non-coverage for CxBladder test code 0012M. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing provided on July 21, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from January 21, 2021, to February 8, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. The Plan says you have been 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). Your contract with the Plan clearly says that you must pay $350 per day for days 1-5 and $0 per day for days 6-90 for each inpatient stay. 

The record shows you were in the hospital from January 21, 2021, to February 8, 2021. Therefore, you have been asked to pay $350 per day for the first five days of inpatient hospital services. The total for your stay is $1750. Inpatient hospital services fall within the Inpatient Hospital 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 hospital services provided from January 21, 2021, to February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second annual physical exam received on August 5, 2021.
You asked the Plan to pay for the services. You say that this should be covered because you received the exam from a new primary care provider after moving to a new residence. The Plan denied your request. The Plan says the annual physical exam benefit is once per year.
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 services, was requested solely for screening purposes, as an annual physical exam was already received during the year. Therefore, we decided that the Plan does not have to pay for a second annual physical exam received on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 29, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 30, 2021.
You asked the Plan to pay for these services. You say that this visit should be covered because you had a referral. The Plan denied your request. The Plan says the Plan has confirmed with the staff at your primary care physician that you did not have a referral, nor did you have prior authorization from the Plan.
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 out of network physician services provided on May 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided August 12, 2021.

You asked the Plan to pay for radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim billed shares a bundled relationship with another claim billed.

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 is a column II code to column I code 70496. 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 radiology services (70450) provided August 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from May 31, 2021, to June 28, 2021.

You asked the Plan to pay for the services. You say that medical records have been submitted to support all denied codes. The Plan denied your request. The Plan says there was incorrect/missing home health data.

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 find that the denied home health services are not supported in the medical record. Specifically, the treatment authorization code is not valid in this case. 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 home health services provided to the enrollee from May 31, 2021, to June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on July 23, 2021.
You asked the Plan to pay for SelectMDx testing. You say that this is recommended for the enrollee's condition. The Plan denied your request. The Plan says this is not supported.
The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx.
We looked at the file and Medicare rules. The testing at issue is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient office visit (99214) provided January 13, 2021.

You asked the Plan to pay for the office visit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that per LCD or NCD guidelines, procedure code 0241U has not met the associated diagnosis code relationship criteria.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 office visit. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the procedure codes in dispute are 0241U. The documentation indicates that the enrollee had diagnoses Z20.822 (contact with and (suspected) exposure to COVID-19), J06.9 (acute upper respiratory infection, unspecified), J44.9 (chronic obstructive pulmonary disease, unspecified), and Z68.21 (body mass index [BMI] 21.0-21.9, adult). She was evaluated on 1/13/2021 for shortness of breath x 2 days, cough and Covid 19 exposure. She had a room air O2 saturation of 88%. Her Covid test was positive, and she was treated with antibiotics and a Medrol Dosepack. The review has determined that the medical records provided met the requirements listed in the LCD for Medicare coverage. The items/services at issue in this case were medically reasonable and necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Therefore, we decided that the Plan has to pay for the outpatient office visit (99214) provided January 13, 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: Favorable

We decided that the Plan has to pre-approve FoundationOne CDx testing.

You asked the Plan to pre-approve FoundationOne CDx testing. You say that the requested FoundationOne CDx testing is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested FoundationOne CDx testing.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 FoundationOne CDx testing. Our reviewer says that the requested FoundationOne CDx testing is medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic adenocarcinoma of the lung with known EGFR mutation. The enrollee's Guardant360 testing on July 29, 2021 was with no new actionable mutations. Medicare says request for NGS testing is met when the patient has either not been previously tested using the SAME NGS test for the same primary diagnosis of cancer, or repeat testing using the SAME NGS test only when a new primary cancer diagnosis is made. The file does not show that the enrollee previously had FoundationOne CDx testing. The documentation supports that the coverage criteria as established by the NCD have been met in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of FoundationOne CDx testing have been met. Therefore, we decided that the Plan has to pre-approve FoundationOne CDx testing.

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: SNF
Decision: Favorable

We decided that the Plan has to pay for the SNF services provided from May 27, 2021, through May 29, 2021.

You asked the Plan to pay for SNF services. You say that you were never made aware that the services would not be covered by the insurance, nor were you given any other options for care for your husband. The Plan denied your request. The Plan says that the SNF services were not medically necessary.

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. Specifically, the Plan has not submitted the medical records to us for review and the Plan has not responded to our request for these medical records. Therefore, we decided that the Plan has to pay for SNF services provided from May 27, 2021, through May 29, 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 cardiology services (93295) provided on May 12, 2021.
You asked the Plan to pay for the cardiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for cardiology services (93295) provided on May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 25, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on May 25, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on August 2, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you do not remember having this service done. 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 $15 copayment for lab services. You have been asked to pay a $15 copayment for the lab services. We confirmed that you did receive these services. The medical records show that your primary care doctor ordered iron testing, a complete blood count, a comprehensive metabolic panel, and thyroid stimulating hormone lab tests for you. 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 lab services you received on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 19, 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 rovider 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 out of network physician services provided to the enrollee on May 19, 2021