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

We decided that the Plan does not have to pre-approve naturopath services.
You asked the Plan to pre-approve naturopath services. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pre-approve naturopath services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant 360 (CPT code(s): 81402, 81403, 81404, 81120) provided to the enrollee on May 5, 2021.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee meets the medical necessity criteria for the requested panel, but the rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. The Plan states they will approve a request for CPT code 81479 if 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.

Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Therefore, we decided that the Plan does not have to pay for Guardant 360 (CPT code(s): 81402, 81403, 81404, 81120) provided to the enrollee on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulmonary risk panel (81302, 81330, 81345, 81404, 81405, 81406, 81407, 81408, 81479) provided September 9, 2020.

You asked the Plan to pay for a pulmonary risk panel. You say that this should be covered. The Plan denied your request. The Plan says this is not supported by a physician order.

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 testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of a pulmonary risk panel have not been met. Therefore, we decided that the Plan does not have to pay for a pulmonary risk panel (81302, 81330, 81345, 81404, 81405, 81406, 81407, 81408, 81479) provided September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy service (code 97110) provided on April 1, 2021.

You asked the Plan to pay for physical therapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the billed service code is not supported.

The Plan must follow Medicare rules. Medicare rules say that coverage of service incident to the professional services of a physician or non-physician practitioner is limited to situations in which there is direct supervision of auxiliary personnel. Medicare rules say that the services of a Physical Therapy Assistant (PTA) must be supervised by a physical therapist and cannot be billed as incident to a physician/non-physician practitioner's service. 

We looked at the file and Medicare rules. Based on the records provided, the credentials of the rendering provider who was sent to the enrollee's home are not clear. However, any auxiliary personnel whose services are billed for by a nurse practitioner must be under the direct supervision of that nurse practitioner. A PTA could provide therapy services without direct supervision, but only when billed by a licensed therapist. The records submitted show no direct supervision by the billing nurse practitioner and no evidence that the nurse practitioner is a licensed therapist. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy service (code 97110) provided on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech generating device and accessories (E2510 and E2599) provided on March 5, 2021.
You asked the Plan to pay for the speech generating device and accessories. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is questionable indication that the treating provider ordered this device, there is no indication in the medical records the treating provider intended for this device to be ordered and multiple coverage criteria specific to the device noted above were not met.
The Plan follows Medicare rules. Medicare rules say that speech generating devices 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 pay for the speech generating device and accessories. Our reviewer says that the documentation submitted does not support that all of the coverage criteria of the applicable LCD were met. Our physician reviewer found it is unclear whether a copy of the written evaluation and recommendation was forwarded to the beneficiary's treating practitioner prior to ordering the device. 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 speech generating device and accessories have not been met. Therefore, we decided that the Plan does not have to pay for the speech generating device and accessories (E2510 and E2599) provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the ankle foot orthosis (AFO) walking boot (L4631) provided March 17, 2021.

You asked the Plan to pay for the orthosis. You say that this new boot has postponed the need for serious foot surgery. You believe the information provides a compelling case to grant your appeal and pay for your necessary medical support. The Plan denied your request. The Plan says that the clinical records submitted with your appeal did not support why you could not utilize a prefabricated AFO rather than a custom AFO.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the services were rendered by an in-network provider. The plan denied as no medical records have been submitted with this review to support the medical necessity for the custom AFO device as opposed to a prefabricated orthosis. Since the provider is in-network with the Plan, it is the Plan's responsibility to obtain the medical records from the provider. The records do not show that the Plan made any attempts to request the medical records from the provider and had failed to receive them. The plan has not made reasonable and diligent efforts to obtain the needed records to substantiate their decision to deny your request. Therefore, we decided that the Plan has to pay for the ankle foot orthosis (AFO) walking boot (L4631) provided March 17, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina injections provided on April 5, 2021.

You asked the Plan to waive the coinsurance for injection, onabotulinumtoxina (J0585). You say that the copayment seems to be in error as the percentage does not seem to match up. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay 20% coinsurance for injection, onabotulinumtoxina (J0585). Injection, onabotulinumtoxina (J0585) falls within the Medicare Part B prescription drugs benefit category. The claim shows you are only being charged for units used. 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 coinsurance for the onabotulinumtoxina injections provided on April 5, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your
request. The Plan says that the care can be received in another setting, such as home, a long-term care facility,
or other outpatient setting.

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
requested admission is medically reasonable and necessary. Our physician reviewer found there are
documented skilled therapy needs. You are functioning below your baseline. A short trial of skilled therapy is
medically necessary and reasonable to improve your strength, endurance, and transfer ability.

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 admission to a
skilled nursing facility (SNF).

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: 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 not medically necessary. 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 based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, 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 admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on December 18, 2020.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee. The Plan denied your request. The Plan says that rules for psychotherapy services have not been met because there is no documentation of consultation with the attending or primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the only exception to the consultation requirement for clinical social workers is in cases where the patient's primary care or attending physician refers the patient to the clinical social worker. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. The medical records document that the enrollee was referred to the clinical social worker by the enrollee's primary care physician. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on December 18, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 the admission. You say that the enrollee would benefit from this. The Plan denied your request. The Plan says the enrollee does not meet the criteria for skilled nursing facility care.

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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does have documented skilled nursing needs, as the enrollee is receiving complete enteral nutrition. The enrollee does not have documented skilled therapy needs, as the enrollee appears to have reached a new baseline in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 

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 admission 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on September 1, 2020.
You asked the Plan to pay for laboratory services. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also 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 find that CPT code 81479 is not supported in the medical record. Specifically, no medical records documenting this service have been submitted. 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 (81479) provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth, partially bony (D7230), removal of an impacted tooth, completely bony (D7240), therapeutic parenteral drug (D9610), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on April 20, 2021.
You asked the Plan to pay for the dental services. You say that you do not feel like you should owe $772. You say that your provider advised that the surgery was approved by insurance. You say that you cannot afford to pay this bill. You also say that you had to put $1,300 on a credit card that you cannot pay. The Plan denied your request. The Plan says the removal of impacted teeth, therapeutic parenteral drug, and deep sedation services are not listed as covered services.
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 removal of an impacted tooth, partially bony (D7230), removal of an impacted tooth, completely bony (D7240), therapeutic parenteral drug (D9610), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on April 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found as of September 23, 2021, you did not require any skilled nursing or skilled rehabilitation services on a daily basis. You are not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. You not require therapy to establish a safe and effective maintenance program. As a practical matter, you do not require skilled services on an inpatient basis, at a SNF level of care, after September 23, 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2790) and core buildup, including any pins when required (D2950) provided on December 8, 2020 by an OON provider.
You asked the Plan to pay for the crown and core buildup. You say that you would like to appeal these services. The Plan denied your request. The Plan says this claim was paid benefits up to the annual maximum allowable for the services received from an OON provider.
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, you are responsible for the difference
between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay for the crown (D2790) and core buildup, including any pins when required (D2950) provided on December 8, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a perfusion scan (78582) provided April 9, 2021.
You asked the Plan to waive the copayment for the scan. You say that you were told there would be a $10 copayment. The Plan denied your request. The Plan says the correct copayment was applied.
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 $250 per day copayment for Diagnostic Radiology. You have been asked to pay a $250 per day copayment for the scan. the scan falls within the Diagnostic Radiology 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 perfusion scan (78582) provided April 9, 2021.