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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 28, 2021, through April 26, 2021.
You asked the Plan to pay for the SNF care provided. You say that it is felt that Medicare payment should be made for these dates. The Plan denied your request. The Plan says the claim was correctly denied as SNF criteria were 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 pay for the SNF care provided. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member is a 55-year-old female with a past medical history including substance abuse who was admitted to an acute hospital due to heroin overdose. She stabilized medically and was admitted to a skilled nursing facility on 3/5/21 for inpatient rehab services. She remained medically stable during her admission in the SNF. The most recent therapy documentation indicates the member is able to ambulate up to 150 feet without assistance and was able to accomplish bed mobility and transfers without assistance. As of 3/28/2021 the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 3/28/2021. 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 SNF care provided have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 28, 2021, through April 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical and occupational therapy home health services.
You asked the Plan to pre-approve the requested home health services. You say that this care is required for the enrollee. The Plan denied your request. The Plan says home health therapy is no longer required.
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 the requested home health services. Our reviewer says that the requested home health therapy is not found to be medically reasonable and necessary. Our physician reviewer found the member is a 78-year-old female with a medical history including chronic lung disease who has been treated with home physical therapy after discharge from an inpatient skilled nursing facility on 9/2/21. The most recent therapy documentation indicates the member is able to ambulate up to 90 feet with a walker with contact guard assistance. She requires contact guard assistance for transferring and moderate assistance for going up and down stairs. She has been taught a home exercise program. In this case, the documentation doesn't support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She has been taught a home exercise program. The requested home health services 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 requested home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical and occupational therapy home health services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the physical therapy (PT) services provided on June 14, 2021, and the self-administered drugs provided from June 10, 2021, to June 14, 2021 during your outpatient hospital stay.
You asked the Plan to waive the charges for the PT services and self-administered drugs. You say that you should owe nothing because this hospital stay was due to COVID. The Plan denied your request. The Plan says this stay was not billed with a COVID diagnosis, and the correct cost sharing was applied.
The rules say that most self-administered drugs are not covered in the outpatient setting by Medicare Part B. 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 copayment for "outpatient rehabilitation services". You were provided with drugs during your hospital stay that are usually self-administered by those who take them. These are not among the types covered by Medicare Part B. You have also been asked to pay a $40 copayment for the PT services and self-administered drugs. The PT services fall within the "outpatient rehabilitation 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 charges for the physical therapy (PT) services provided on June 14, 2021, and the self-administered drugs provided from June 10, 2021, to June 14, 2021 during your outpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal from an endodontist.
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 services from an endodontist are not covered.
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. The Plan covers supplemental dental benefits from a participating general dentist only. Therefore, we decided that the Plan does not have to pre-approve a root canal from an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bladder instillation of an anti-carcinogenic agent provided on February 26, 2021, billed with code 51720-59.
You asked the Plan to pay for the bladder instillation as billed. You say that all billed codes should be paid. The Plan denied your request. The Plan says code 51720 is bundled with code 52240.
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only the Column 1 code is payable unless a clinically appropriate modifier is used. We asked our coding 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 bladder instillation as billed. Our reviewer says that the use of modifier -59 is not supported to bypass the NCCI edit. Our reviewer found the documentation supports bladder instillation was given right after the primary service. To appropriately report CPT 51720 with modifier 59, the procedure would be separate from the primary service and performed at a separate encounter on the same day. 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 bladder instillation as billed have not been met. Therefore, we decided that the Plan does not have to pay for the bladder instillation of an anti-carcinogenic agent provided on February 26, 2021, billed with code 51720-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for digital hearing aids received March 24, 2021.
You asked the Plan to pay for digital hearing aids. You say that the measurements of your hearing loss is in the Plan's records. The Plan denied your request. The Plan says the benefit limit of $1,500 has been exhausted.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to a benefit limit of $1,500. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of digital hearing aids have not been met. Specifically, the record shows that you have exhausted the Plan's benefit limit of $1,500, for hearing aids. Therefore, we decided that the Plan does not have to pay for digital hearing aids received March 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional home health physical therapy (PT) visits.
You asked the Plan to pre-approve the additional home health services. You say that this should be approved. The Plan denied your request. The Plan says the requested PT is no longer medically necessary.
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 the additional home health services. Our reviewer says that the requested additional PT services are not considered medically reasonable and necessary. Our physician reviewer found the documentation doesn't support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Her function has improved with therapy and she and her caregivers should be independent with a home exercise program. The requested home health services 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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional home health physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve these services. You say that you need a portable oxygen concentrator that you can take with you when you leave. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the gynecological office visit provided on January 7, 2021, and the gynecological visit with obstetric ultrasound provided on January 28, 2021.
You asked the Plan to waive the charges for the office visits and ultrasound. You say that you feel this is billed incorrectly. The Plan denied your request. The Plan says these cost shares were correctly applied.
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 there is a $198 deductible which applies to in and out of network specialist service and 30% coinsurance for diagnostic testing provided out of network.
The item or service you asked the Plan to waive the charges for falls within the benefit category "in and out of
network specialist services". The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $198 deductible which applies to in and out of network specialist services. This cost sharing is a
contractual obligation that had not been met at the time the office visits were received on January 7, 2021 to
March 2, 2021. The ultrasound falls into the benefit category "out of network diagnostic testing". Therefore,
we decided that the Plan does not have to waive the charges for the gynecological office visit provided on
January 7, 2021, and the gynecological visit with obstetric ultrasound provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient hospital diagnostic services provided on March 16, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that the Medicare data shows that the enrollee was not in a skilled nursing facility (SNF) stay on this date of service. The Plan denied your request. The Plan says that per the authorization history, the enrollee was discharged from the hospital on March 12, 2021 and admitted to the SNF. Payment for all services during a covered SNF stay must be billed and paid by the SNF.
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. The Plan has failed to provide evidence to support its denial rationale. There is no evidence presented to support that the enrollee was in a Part A-covered SNF stay on this date of service. The provider has showed evidence from the Medicare Administrative Contractor, which does reflect the hospital stay from February 27, 2021, through March 12, 2021, but shows no SNF stay. A paid claim would be required to support that Part A covered SNF care was being provided. Therefore, we decided that the Plan has to pay for the outpatient hospital diagnostic services provided on March 16, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames, trifocal eyeglass lens, anti-reflective lens coating, trifocal eyeglass lens (V2020, V2303, V2750, V2304).
You asked the Plan to pay for the eyeglasses. You say that you have not exhausted your benefit. The Plan denied your request. The Plan says you have exhausted your 2021 benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services by providing a $150 allowance every 24 months to pay for eyewear. We looked at the file and the Plan's rules. You have exceeded the $150 allowance allotted for eyewear. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames, trifocal eyeglass lens, anti-reflective lens coating, trifocal eyeglass lens (V2020, V2303, V2750, V2304).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the nuclear stress test provided on May 28, 2021.
You asked the Plan to reduce the cost sharing for the nuclear stress test. You say that this service should be considered an x-ray with a $15 copayment. The Plan denied your request. The Plan says this imaging is not a standard x-ray and was correctly assessed the diagnostic imaging copayment.
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 $75 copayment for "Medicare-covered diagnostic radiology services". You have been asked to pay a $75 copayment for the nuclear stress test. The nuclear stress test falls within the "Medicare-covered diagnostic radiology services" benefit category. This is not considered an x-ray or ultrasound. 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 sharing for the nuclear stress test provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from August 1, 2020, through August 31, 2020.
You asked the Plan to pay for the SNF services. You say that the documentation provided is the most reasonable source for functional status information for use in the MDS form. The Plan denied your request. The Plan says that the activity of daily living (ADL) category report and the point of care history documentation cannot be used to support coding in Section GG of the SNF billing information.
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. The Plan has failed to provide a compelling rationale to support the reduction of payment in this case. The Plan's denial centers on its audit findings that the ADL category report and point of care history is not sufficient to support the reporting of the enrollee's functional abilities as reported in the Minimal Data Set (MDS) assessment. However, review of these records show that they are filled out by qualified SNF stay working with the patient directly on a daily basis. Though each date does not include a full skilled nurse/therapist note detailing each item on the chart, this is a primary source of information reported by the treating team during the enrollee's stay. It is unclear the reason that the Plan believes this to be invalid information. The Plan's citation from the SNF billing manual is: "A resident's usual functional status assessment is determined by qualified healthcare professionals practicing within their scope of practice". It appears that this is precisely the information that the charts capture from the treating professional directly. Without a valid and specific rationale or alleged discrepancies between what is documented in the chart and what was reported on the MDS assessment form, we find that the denial is not substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from August 1, 2020, through August 31, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day or adjust insulin dosage based on blood glucose test results. 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 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastrointestinal pathogen panel with multiplex nucleic acid amplification provided on May 3, 2021.
You asked the Plan to pay for the gastrointestinal pathogen panel. You say that this was medically necessary. The Plan denied your request. The Plan says there is no documentation of immunodeficiency.
The Plan follows Medicare rules. Medicare rules say that gastrointestinal pathogen panels are considered medically necessary for those with compromised immune systems. 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 gastrointestinal pathogen panel. Our reviewer says that the gastrointestinal pathogen panel is not shown to meet coverage criteria.
Our physician reviewer found the enrollee had a diagnosis of diarrhea, unspecified. Infectious agent detection, gastrointestinal pathogen, code 87507, is covered by Medicare in beneficiaries with immunodeficiency. There is no documentation of immunodeficiency. The review has determined that the enrollee did not meet the criteria for this request. 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 gastrointestinal pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the gastrointestinal pathogen panel with multiplex nucleic acid amplification provided on May 3, 2021.