Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-care/home management training provided on June 18, 2020.  

You asked the Plan to pay for the self-care/home management training. The Plan denied your request. The Plan says codes G0482 and 80305 were approved and CPT code 97535 remains not supported.  

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, 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. Based on this information, we decided that Medicare rules for coverage of the self-care/home management training have not been met. Specifically, medical records were not submitted to determine if Medicare coverage criteria has been met. Therefore, we decided that the Plan does not have to pay for the self-care/home management training provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).

You asked the Plan to pay for the dental services. You say that you had not had an oral exam since 2020. You say that your coverage allows for 2 exams per year. You also say that this exam should be covered. The Plan denied your request. The Plan says 1 periodontal or comprehensive oral evaluation every 3 years. The Plan also says that the frequency limit has been exceeded.

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 and the requested service is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a comprehensive oral evaluation that you received on May 19, 2020. requested items or services are not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 20, 2021.  You asked the Plan to pay for the ambulance service. You say that you had a severe bloody nose. You say that you called 911 because of the medications you take. You say that you did not need to be transported to the hospital. You also say that you did need medical attention. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since no transport was provided there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99202) and X-ray services (72040, 72070, 72100, 72170) provided on July 6, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has processed correctly based on Medicare rules for chiropractic coverage.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and X-ray services (72040, 72070, 72100, 72170) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Genesight testing (81479) provided on February 12, 2021.  You asked the Plan to pay for Genesight testing. You say that this was medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that in order for Pharmacogenomics Testing services to be covered, the patient's medical record must clearly reflect that the criteria listed in the rules section have been met.  We looked at the file and Medicare rules. The submitted medical records do not include records from the ordering provider demonstrating that the criteria for coverage have been met and that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and appliance (E0675 and E0673).

You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and appliance (E0675 and E0673).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued care with an out-of-network psychologist.  

You asked the Plan to pre-approve psychotherapy visits. You say that the enrollee has seen this provider for almost 25 years, and she cannot start over with a new provider. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.  

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 psychotherapy visits. Our reviewer says that the enrollee does not meet the Medicare criteria for continuity of care with the out-of-network provider. Our physician reviewer found the enrollee does not require treatment by an out-of-network provider because she is being treated for a non-emergent condition. The enrollee's care can be safely transitioned to an in-network therapist.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network psychologist.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollees' condition. The Plan denied your request. The Plan says rules for SNF care have 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 beneficiary 63-year-old female with congestive heart failure and altered mental status. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a podiatry visit provided on July 13, 2021.  You asked the Plan to waive the copayment for the podiatry visit. You say that the provider informed you that routine nail care was covered every three months. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each podiatry visit.   You have been asked to pay a $40 copayment for the podiatry visit. Please note that although the service is covered, the copayment still applies. Podiatry visits fall within the Podiatry 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 copayment for a podiatry visit provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia services (99100) provided on June 3, 2021.

You asked the Plan to pay for special anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99100 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services (99100) provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crutch substitute (E0118).

You asked the Plan to pre-approve the crutch substitute. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

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 crutch substitute. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal any medical progress notes with an objective physical examination of the patient and there is no evidence that the requested crutch substitute is safe and effective for this patient. 

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 crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve the crutch substitute (E0118).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on January 27, 2021.

You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame.

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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee.

The progress note for January 27, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the behavioral health services provided on May 25, 2021.  You asked the Plan to pay for the behavioral health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), an anti-reflective coating (V2750) and a non-medically necessary service (S9986) provided on September 16, 2021.  

You asked the Plan to pay for vision services. You say that vision benefits are covered by your Plan. You also say that because of poor eyesight, you need to be treated every year by a vision provider. The Plan denied your request. The Plan says the services requested exceed the maximum benefit limit.  

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 contract says that you are limited to one routine eye exam every year. The Plan also says you received a $100 allowance towards your purchase of standard lenses and frames every 2 years.  

We looked at the file and the Plan's rules. The records show the eye exam and refraction have been paid by the Plan. The records also show that you received eyeglasses on June 10, 2020, therefore, you have exhausted your Plan benefits. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), polycarbonate lenses (V2784), an anti-reflective coating (V2750) and a non-medically necessary service (S9986) provided on September 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (93880), provided on June 23, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $160 copayment for the ultrasound. The ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound (93880), provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for injections of tendon sheath, ligament, or muscle membrane (20550) provided from June 24, 2021, to August 4, 2021.  

You asked the Plan to waive the copayment for injections of tendon sheath, ligament, or muscle membrane. You say that the doctor gave you a cortisone shot at each of three visits and that this was in an exam room. You also state that at no time was this done in an operating room. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $385 copayment for Medicare-covered surgery or other services provided to you in an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.   

You have been asked to pay $285, which is less than the $385 copayment for each injection of tendon sheath, ligament, or muscle membrane for three visits. T Injections of tendon sheath, ligament, or muscle membrane fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for injections of tendon sheath, ligament, or muscle membrane (20550) provided from June 24, 2021, to August 4, 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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or an assisted living facility with home health care or in a long-term care facility on a part time basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.