Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital evaluation and management (EM) services provided on April 22, 2021, billed with code 99221.
You asked the Plan to pay for the initial hospital EM services. You say that this should be paid as it was billed correctly. The Plan denied your request. The Plan says this service was provided during the 90-day global period of the thromboendarterectomy procedure performed on March 11, 2021, billed with code 35355. Since this was not billed with modifier -24, separate payment cannot be made.
The Plan must follow Medicare rules. Medicare rules say that in order to be paid for EM services unrelated to a prior global surgery within the global period, providers must use modifier -24 to report these unrelated services. We looked at the file and Medicare rules. Modifier -24 was not reported for code 99221. Based on this information, we decided that Medicare rules for coverage of the initial hospital EM services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital evaluation and management (EM) services provided on April 22, 2021, billed with code 99221.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on October 19, 2020.
You asked the Plan to pay for the emergency department visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says it is your responsibility to bill the primary payer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment.
Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541,
87581, 87634, 87640, 87798) provided on September 21, 2020.

You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied
your request. The Plan says this was billed with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The claim for these services was billed with an office place of
service, but the records indicate that the sample was taken in a nursing facility. Based on this information, we
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87634,
87640, 87798) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CORUS test) provided to the enrollee on August 13, 2020.
You asked the Plan to pay for the services. You say that this is was medically necessary. The Plan denied your request. The Plan says since initial coverage of the assay, the manufacturer has failed to demonstrate that testing resulted in improved patient outcomes or that testing changed physician management to result in improved patient outcomes.
The Plan must follow Medicare rules. The rules say that the CORUS coronary artery disease (CAD) test is not covered.
Coverage is no longer available for the denied testing. 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 laboratory services (CORUS test) provided to the enrollee on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on July 13, 2021.

You asked the Plan to pay for the services. You say that you were not aware that prior authorization was not made. The Plan denied your request. The Plan says the claim processed appropriately.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental services with an allowance of up to $500 per year.

The case file shows that with services received on June 28, 2021 and July 13, 2021, the $500 benefit maximum has been met. There was $205 paid for June 28, 2021, and $295 paid for the date of service at issue in this case. The remaining charges on the claim are your responsibility. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Barostim Neo System.
You asked the Plan to pre-approve the Barostim Neo System. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is an experimental/investigational procedure.
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 Barostim Neo System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are insufficient data regarding the safety and effectiveness of the Barostim Neo System, and there is a need for longer-term data. Consequently, the system cannot be considered medically reasonable and necessary for the enrollee 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 the Barostim Neo System have not been met. Therefore, we decided that the Plan does not have to pre-approve the Barostim Neo System.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home physical therapy visits (CPT code G0151 X 11), for the enrollee.
You asked the Plan to pre-approve the home physical therapy visits. You say that the enrollee would continue to benefit from medically necessary skilled intervention in order to address the deficits affecting the enrollee's independence in performing the function, activities safely, as well as from an updated home exercise program (HEP), to reinforce safety in functional activities and, thereby, prevent falls/prevent rehospitalization. The Plan denied your request. The Plan says the records do not support the need for a skilled physical therapist to make more home visits. 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 home physical therapy visits. Our physician reviewer found there is no documentation that further skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Records indicate the enrollee in independent/stand-by assist for transfers and is ambulating 150-250 feet with supervision with a single point cane and is stand-by assist for stairs and has been instructed on a home exercise program. Further utilization of the home exercise program appears appropriate at this point. 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 home physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the home physical therapy visits (CPT code G0151 X 11), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health/hospice aide services provided from May 3, 2021 to May 22, 2021.
You asked the Plan to pay for the home health/hospice aide services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes. We find that CPT code G0156 is not supported in the medical record. Specifically, the documentation does not include documentation of the time spent on the services rendered. Based on this information, we decided that Medicare rules for coverage of the home health/hospice aide services have not been met. Therefore, we decided that the Plan does not have to pay for the home health/hospice aide services provided from May 3, 2021 to May 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Ilumya. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision (11406), trunk repair (13101) and implantation of a biologic implant (15777x2) provided on March 26, 2019.

You asked the Plan to pay for the incision, trunk repair and implantation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure codes 11406-AS-59, 13101-AS-59, 15777-AS-LT and 15777-AS-RT are not valid codes for assistant at surgery services.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 11406, 13101 and 15777. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the incision, trunk repair and implantation have not been met. Therefore, we decided that the Plan does not have to pay for the incision (11406), trunk repair (13101) and implantation of a biologic implant (15777x2) provided on March 26, 2019.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member cannot go to a skilled nursing facility and needs to be admitted to an acute inpatient rehabilitation facility. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis, colitis, and pneumonitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services you received on
October 20, 2020, to December 7, 2020.

You asked the Plan to waive the copayments for the specialist services. You say that your insurance agent told
you that specialist copayments were waived through the end of December. The Plan denied your request. The
Plan says you were charged these copayments correctly. The Plan says that it only waived specialist
copayments from August 24, 2020, to September 30, 2020. The Plan says that it waived copayments for
primary care visits through December 31, 2020.

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 $35
copayment for services with a specialist.

The Plan cannot be held responsible for incorrect information provided to you by your insurance agent. Please note that the Plan's website explicitly states that non-primary care copayments will not be waived starting October 1, 2020. You have been asked to pay a $35 copayment for the specialist 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 copayments for specialist services you received on October 20, 2020, to December 7, 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. ed 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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64491 provided on February 17, 2021.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 64491 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection
services coded 64491 provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for repair of superficial wounds (12011) provided on January 27, 2021.
You asked the Plan to pay for the repair of superficial wounds. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this code is included in Current Procedural Terminology (CPT) 21310; therefore, it cannot be separately reimbursed.
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 the repair of superficial wounds has a bundled relationship with code 12130 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 repair of superficial wounds (12011) provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left lower and sacral spine facet joint injections.
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 facet joint injections are 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 services are not medically necessary. Our physician reviewer found the enrollee has back pain that has been treated with medical therapy and lumbar medial branch blocks (MBBs) on August 9, 2021. Her pain level is now rated at 8 out of 10 across her bilateral low back. The criteria for coverage of the requested facet injections are not met; therefore, the injections are 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 left lower and sacral spine facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on January 4,
2021.
You asked the Plan to pay for this service. 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 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 physician services provided to the enrollee on
January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D hydroxy provided on February 2, 2021.
You asked the Plan to pay for Vitamin D hydroxy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 Vitamin D hydroxy test at issue in this appeal 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 Vitamin D hydroxy provided on February 2, 2021.