Persius/hicric huggingface dataset:
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be reassessed when medically stable for 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 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray of the chest (71046) provided on May 19, 2021.  You asked the Plan to pay for the X-ray of the chest. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says separate payment is not made for this service according to Medicare rules.  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 test at issue in this appeal, the X-ray of the chest, was requested solely for screening purposes. These services as billed are not separately payable. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the X-ray of the chest (71046) provided on May 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on July 18, 2021.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that the transportation was medically necessary, and you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the criteria for coverage are not met.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ground mileage and non-emergency ambulance transportation. Our reviewer says that the documentation does not support that the ambulance transport on July 18, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this patient. Our reviewer also found that the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on July 18, 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 ground mileage and non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on July 18, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for GeneSight testing provided on August 18, 2021.  You asked the Plan to pay for GeneSight testing. You say that no basis exists for the Plan to deny payment of this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this test is not covered, was not billed with the appropriate DEX Z-Code, has not been shown to be useful, and was not medically necessary and appropriate.  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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. Medicare rules say that a pharmacogenomics test service must be billed with the appropriate Current Procedural Terminology (CPT) code, DEX Z-Code, and International Classification of Diseases 10 Clinical Modification (ICD-10-CM) code.  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 did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Furthermore, the Plan did not submit a copy of the original claim form billed for this testing. Without a copy of the claim form, we cannot determine whether this claim was billed in accordance with Medicare billing rules. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for GeneSight testing provided on August 18, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676).  You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered service.  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 (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for imaging services (93925, 93922) provided on August 24, 2021.  You asked the Plan to waive the copayment for the imaging services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.       You have been asked to pay two $50 copayments for imaging services. Imaging services 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 imaging services (93925, 93922) provided on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the CT scan provided on September 21, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that the copayment is not listed on your member ID care and should not be liable for the cost share. The Plan denied your request. The Plan says you have been asked to pay 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 $225 copayment for in-network advanced imaging service (not including x-rays). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $225 copayment for the CT scan.    You have been asked to pay a $216.06 copayment for the CT scan. The CT scan 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 CT scan provided on September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a knee x-ray provided to the enrollee on July 23, 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 this was not billed correctly.  

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 73564 is "Radiologic examination, knee; complete, 4 or more views."  

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 the documentation from the provider states "this study will be dictated by the referring orthopedic provider." A radiology interpretation from the billing provider was included in documentation submitted. The provider is reporting the professional component of the x-ray taken. Per the CPT guidelines - "Any specifically identifiable procedure (ie, identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent E/M service should be reported separately.  The actual performance and/or interpretation of diagnostic tests/studies ordered during encounter are not included in the levels of E/M services." The interpretation of the radiology service should be reimbursement separate from the evaluation and management services provided.
  
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 a knee x-ray provided to the enrollee on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the duplex scan provided on February 23, 2021.  

You asked the Plan to waive the copayment for the duplex scan. You say that the scan was required to see if the vein procedure was successful. You say the scan was not diagnostic. The Plan denied your request. The Plan says you have been asked to pay 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 $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic).   

You have been asked to pay a $110 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the duplex scan is considered a separate service. 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 duplex scan provided on February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial hospitalization admission.  You asked the Plan to pre-approve a partial hospitalization admission. You say that the requested service is medically necessary. The Plan denied your request. The Plan says you can safely be managed on an outpatient basis.  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 a partial hospitalization admission. Our reviewer says that the requested partial hospitalization is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation shows that you were not showing any dangerousness to self or others and not showing any perceptual disturbance or psychosis, according to the intake documentation. The reviewer also found that based on the American Association of Community Psychiatrists Level of Care Utilization System, the requested level of care is not medically reasonable or 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 a partial hospitalization admission have not been met. Specifically, the file does not indicate any dangerousness to self or others. Therefore, we decided that the Plan does not have to pre-approve a partial hospitalization admission.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on December 14, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had a diagnosis of depressive type schizoaffective disorder. The case file contains a GeneSight Order Medical Necessity Documentation form, and the results of the GeneSight testing. The case file does not contain additional clinical information. The documentation is insufficient to support that the GeneSight genetic testing was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infrared light therapy (97026) provided January 21, 2021.  You asked the Plan to pay for the infrared light therapy. You say that please see attached medical records and process this claim. The Plan denied your request. The Plan says this service is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared light therapy have not been met. Therefore, we decided that the Plan does not have to pay for the infrared light therapy (97026) provided January 21, 2021.
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely provided at an alternate and less intense setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Spriva Respimat inhaler.  

You asked the Plan to pre-approve a Spriva Respimat inhaler. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Spriva Respimat inhaler.   

Benefits for a Spriva Respimat inhaler may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room visit (99258) provided on November 21, 2021.  You asked the Plan to pay for the critical care services. You say that you received a bill for $1,795. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the emergency room visit (99258) provided on November 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant maintenance procedures (D6080) provided on January 28, 2021.  You asked the Plan to pay for the implant maintenance procedures. You say that you spoke with the dental department prior to enrolling in this plan and were advised that the implant cleanings would be covered. The Plan denied your request. The Plan says this implant service is not a covered benefit under your plan. The Plan also says that you did not contact the Plan's customer service department prior to this date of service to verify benefits and provider eligibility.  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. Therefore, we decided that the Plan does not have to pay for the implant maintenance procedures (D6080) provided on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray provided to the enrollee on September 17, 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/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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray provided to the enrollee on September 17, 2021.