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

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  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 qualify for SNF coverage.  The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care.  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 SNF care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share ($859.68) charged for skilled nursing facility services provided from December 22, 2020, to December 31, 2020.  You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says you transferred from one facility to another. You were an inpatient from December 22, 2020, through December 31, 2020. This claim processed with an $859.68 inpatient  copay, which is less than the traditional copayment of $160 per day.  The Plan states a benefit period begins the day a member goes into a hospital or skilled nursing facility. The benefit period ends when the member hasn't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. Medicare-covered skilled nursing facility care is subject to a $0 copay, per day for days 1-20 and $160 copay, per day for days 21- 100.   The records show the first SNF benefit period was from October 13, 2020 through October 31, 2020 for 19 days and a $0 copay was correctly assessed for the benefit period. The second SNF benefit period was for five days, November 1, 2020 through November 6, 2020.  The claim processed with the lesser copay because the 2020 out-of-pocket maximum was met for the 2020 benefit year but was processed correctly per the plan's benefits for skilled nursing facility care.  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 there is a copayment structure for skilled nursing facility services. In this case you were asked to pay less than the normal contractual obligation for this service. 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 cost share ($859.68) charged for skilled nursing facility services provided from December 22, 2020, to December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 98960 billed for date of service October 28, 2020.  You asked the Plan to pay for procedure code 98960. You say that this service was provided to the patient and was reasonable and necessary. The Plan denied your request. The Plan says this code is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of 'B' are never separately payable.  You billed code 98960.  This code has a status indicator of 'B', so no separate payment is allowable for this code. Therefore, we decided that the Plan does not have to pay for procedure code 98960 billed for date of service October 28, 2020.
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 the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiovascular risk assessment panel provided to the enrollee on August 21, 2020.  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 Medicare coverage criteria are not met.  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 pay for these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether the requested genetic testing was medically reasonable and necessary. The test is described by the manufacturer, Redwood Lab Services, as a genetic-based cardiovascular risk factor screening test in which 62 genes are assessed using genomic DNA extracted from buccal swabs. The test has not been approved by the FDA. It assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk.  It is not a diagnostic test. There is no evidence to support its role in this patient's clinical management. In summary, the requested testing is not considered 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 pay for cardiovascular risk assessment panel provided to the enrollee on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for observation services at an outpatient hospital facility you received from June 30, 2021, to July 1, 2021.  You asked the Plan to waive the copayment for the observation services. You say that you were transported to the hospital from another facility to have an MRI (magnetic resonance imaging.) You don't think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for these services ($221.07) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for outpatient hospital observation services.   You have been asked to pay a $225 copayment for the observation services. This copayment applies regardless of the reason for the 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 observation services at an outpatient hospital facility you received from June 30, 2021, to July 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427, A0425) provided on April 12, 2021.  You asked the Plan to waive the copayment for the ambulance transportation services. You say that you have insurance and do not understand why you are getting these bills. The Plan denied your request. The Plan says you are responsible for a $265 copayment for ambulance transportation. The provider billed $1,175 for these services, and you are being asked to pay $265. This claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $265 copayment for each one-way ground ambulance trip.   You have been asked to pay a $265 copayment for the ambulance transportation. 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 emergency ambulance transportation services (A0427, A0425) provided on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a CT scan provided on April 1, 2021, and April 2, 2021.  You asked the Plan to pay for a CT scan. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity.   The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of a  CT scan have not been met. Therefore, we decided that the Plan does not have to pay for a CT scan provided on April 1, 2021, and April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services, initial 15 minutes (97810) provided on March 22, 2021 to May 31, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the acupuncture services. You say that in an effort to reduce the pain and discomfort you underwent 4 sessions of acupuncture. This provided minimal relief. You are therefore requesting that your claims for acupuncture be approved. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 acupuncture services, initial 15 minutes (97810) provided on March 22, 2021 to May 31, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score (CPT code 81539) provided to the enrollee on July 14, 2020.

You asked the Plan to pay for the services. You say that there is an LCD for the 4K score test which provides access nationwide for Medicare beneficiaries under Medicare's Fee for service program. The Plan denied your request. The Plan says the 4Kscore Test Algorithm's goal is to refine patient selection for biopsies to reduce unnecessary biopsies in men being considered for biopsy of the prostate for potential cancer. The Plan states the clinical features of this group of men are poorly defined and not a Medicare benefit.

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 services. Our physician reviewer found the 4Kscore Test Algorithm's goal is to refine patient selection for biopsies to reduce unnecessary biopsies in men being considered for biopsy of the prostate for potential cancer. The clinical features of this group of men are poorly defined. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage.

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 pay for oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score (CPT code 81539) provided to the enrollee on July 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The records do not show that you require skilled nursing or therapy services on a daily basis. Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not met.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on June 7, 2021.  You asked the Plan to pay for the therapeutic parenteral drug. You say that you needed a root canal. You say that the previous crown was splintered during the process. You also say that you did not have any choice but to get a new crown. The Plan denied your request. The Plan says therapeutic parenteral drug is not listed as a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the therapeutic parenteral drug is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for eye care services provided on June 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON eye care services. You say that you are making a claim payments appeal request on behalf of your patient. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.    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 eye care services provided on June 26, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pneumatic compression devices (E0651, E0667) to be provided by an out-of-network provider.  You asked the Plan to pre-approve pneumatic compression devices. You say that the specific requested medically necessary items can only be provided by the out-of-network provider. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 pneumatic compression devices (E0651, E0667) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity.  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 step therapy requirement is not met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drugs, an oral bisphosphonate and either zoledronic acid or Prolia. The records do not show that the required drugs would be contraindicated or less effective; therefore, Evenity is 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 Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the extractions (D7210) for teeth # 19 and 30 provided on April 28, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that you have a balance of $1,087.77. You also say that you do not understand why you are receiving a bill when you have insurance for dental services. The Plan denied your request. The Plan says major dental services, including extractions, have a 50% coinsurance after the $100 annual deductible has been met. The Plan also says that the claim was processed correctly.The Plan says that that the extractions were processed with an allowed amount of $453.64 and the $100 deductible was applied. $453.64 - $100 = $353.64. The Plan says that the 50% coinsurance was then applied. $353.64 x 50% = $176.82.  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, there is a 50% coinsurance after the $100 annual deductible has been met for extractions. The record shows that each extractions was processed with an allowed amount of $453.64 and the $100 deductible was applied. $453.64 - $100 = $353.64. The 50% coinsurance was then applied to the extractions. $353.64 x 50% = $176.82. You are responsible for $176.82 coinsurance + $100 deductible = $276.82. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the extractions (D7210) for teeth # 19 and 30 provided on April 28, 2021.