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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan 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 you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the psychotherapy services (90832, 90834,
90837) rendered by the out-of-network (OON) provider from February 26, 2021, through April 2, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider and were not urgent nor emergent.
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 issue reimbursement 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we
decided that the Plan does not have to issue reimbursement for the psychotherapy services (90832, 90834,
90837) rendered by the out-of-network (OON) provider from February 26, 2021, through April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of network consultation.
You asked the Plan to pre-approve out of network services. You say that it is medically necessary for you to be
treated out of network. The Plan denied your request. The Plan says this treatment can be provided in network.
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 pre-approved care. 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 out of network services. Our reviewer says that Medicare coverage criteria are not met.
Our physician reviewer found the documentation supports that the Plan is offering adequate care to meet your
medical needs through referral to the in-network obstetrician-gynecologist-oncologist. No unique features are
identified that that would make it medically necessary for out-of-network 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 out of network services have not been met.
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 out of network services. Therefore, we decided that the
Plan does not have to pre-approve an out of network consultation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transcranial doppler study of the intracranial arteries (93892) provided on February 19, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $50 copayment for all other Medicare-covered outpatient diagnostic tests. You have been asked to pay a $50 copayment for the Medicare-covered outpatient diagnostic test provided. 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 transcranial doppler study of the intracranial arteries (93892) provided on February 19, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 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 SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do have documented skilled therapy needs. You are functioning below your baseline following two recent hospitalizations. You have not yet been shown to have reached a new plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Your care needs, as a practical matter, cannot 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for two units of muscle-skin graft to trunk (15734) March 26, 2021.
You asked the Plan to pay for two units of muscle-skin graft to trunk. You say that the billing of this service is supported in the records. The Plan denied your request. The Plan says the billing of two units of 15734 is not supported by the medical records submitted
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 asked our coder 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 two units of muscle-skin graft to trunk. Our reviewer says that the billing of two units of muscle-skin graft to trunk (15734) is not supported. Our reviewer found that the operative report does not document a flap was created from a donor site with vascular supply, as well as repair of the donor site to confirm this procedure has been confirmed. Per documentation "I then created bilateral subcutaneous flaps after the lateral edge of the rectus abdominis muscle and dissected the soft tissue off the midline for approximately 5 cm proximally and distally".
If procedure was performed, this is 1 unit of service, and additional units should not be reported. The documentation submitted does not support the billing of two units of 15734. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of two units of muscle-skin graft to trunk have not been met. Therefore, we decided that the Plan does not have to pay for two units of muscle-skin graft to trunk (15734) March 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan 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 have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near her baseline. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on December 17, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 out of network services provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and injection services provided July 5, 2021.
You asked the Plan to pay for the office visit and injection services. You say that these services were medically necessary. The Plan denied your request. The Plan says these dental services are not covered by Medicare or the Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the office visit and injection services provided July 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient
hospital facility on May 4, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you are appealing this amount.
The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that
because the allowed amount for the lab services ($13.39) 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 $15
copayment for lab services at an outpatient hospital facility.
You have been asked to pay a $15 copayment for the lab 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 lab services you received at an outpatient hospital facility on May 4, 2021. Please note that this
decision is limited to the lab services on May 4, 2021. If you wish to appeal other services, please contact the
Plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (99222) provided to the enrollee on April 16, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a modifier was not billed on the claim to represent the services as separate or distinct.

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 99222 is "Initial hospital care, per day, for the evaluation and management of a patient." 

We asked our coder 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 reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case the record indicates that modifier 25 was not used. The elements of the coverage criteria were not satisfied. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services (99222) provided to the enrollee on April 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system supplies.
You asked the Plan to pre-approve Omnipod disposable insulin pump system supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested supplies are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are non-covered devices. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Omnipod disposable insulin pump system supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1851).
You asked the Plan to pre-approve the knee orthosis. You say that the orthosis is medically necessary. The Plan
denied your request. The Plan says your records show you have knee pain, but your records do not demonstrate
recent injury or surgery or that instability of your knee was found on physical exam.
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 knee orthosis. Our physician
reviewer found the review indicates that you saw your provider on July 22, 2021, for a knee brace fitting;
however, we did not receive notes from the prescribing provider to show an exam was done to demonstrate
laxity/instability. The review has determined that the medical records provided do 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 knee orthosis have not been met.
Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1851).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (CPT code(s): 80053, 84443) provided on May 28, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that you had a yearly exam done and this should be covered in full. You state you do not feel there should be a copayment for it. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you had an annual exam and had laboratory services done on May 28, 2021. You were asked to pay a $10 copayment for the laboratory services. Any additional tests or laboratory services that may be required as a result of the findings of your annual wellness visit would be billed separately by your doctor and would fall under a different benefit than your annual wellness visit. Your 2021 EOC states that enrollees must pay a $10 copayment for Medicare-covered lab services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services (CPT code(s): 80053, 84443) provided on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for vacuum drainage collection unit and tubing kit (A7048) provided February 19, 2020, to June 15, 2020.
You asked the Plan to pay for vacuum drainage collection unit and tubing kit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says exceeds the MUE limit.
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 A7048 is 2 per day. The MAI value for this code is 2 per day. The dates of service are 38 days. 38x2 = 76 units. You billed 145 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of vacuum drainage collection unit and tubing kit have not been met. Therefore, we decided that the Plan does not have to pay for vacuum drainage collection unit and tubing kit (A7048) provided February 19, 2020, to June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), prophylaxis (D1110), and
panoramic x-ray (D0330) provided on June 4, 2021.

You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that
the provider in this case was in network. You also say that you pay for the enhanced dental benefit and should
not have to pay for anything. The Plan denied your request. The Plan says the provider in this case is out of
network. The Plan says dental services performed out of network require prior-authorization. The Plan also
says there is no record of a call made regarding the provider's network status prior to the date of 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the file shows that the provider in this case is
out of network. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220),
prophylaxis (D1110), and panoramic x-ray (D0330) provided on June 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on May 26, 2021.
You asked the Plan to pay for an emergency department visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with a required diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). We looked at the file and Medicare rules. The first and only diagnosis code on the claim for the service at issue, T50.Z95A, is an adverse effect code that requires the nature of the effect to be coded first. Based on this information, we decided that Medicare rules for coverage of an emergency department visit have not been met.
Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on May 26, 2021.