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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 3, 2021, to May 2, 2021.
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says skilled care was no longer 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. This enrollee did 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 the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 3, 2021, to May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device provided on March 19, 2021.

You asked the Plan to pay for the services provided. You say that the device helps prevent the onset of deep vein thrombosis. The Plan denied your request. The Plan says the device is excluded from coverage.

The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered under certain medical indications.

We looked at the file, and Medicare rules. Items that are used for a preventative service or function are excluded from coverage. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the colorectal screening provided on May 5, 2020 to May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the colorectal screening. You say that the hospital should not be penalized for the primary care physician for not obtaining a prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the colorectal screening provided on May 5, 2020 to May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) and endodontic therapy (D3320) provided on January 4, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the prefabricated post and core and endodontic therapy. You say that you received a letter from the Plan requesting that you pay the Plan a $1,000 refund for a claim that was already paid, for services that were not yet performed. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective October 2, 2017, to October 2, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.
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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) and endodontic therapy (D3320) provided on January 4, 2021 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hernia repair surgery to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the hernia repair surgery. You say that you are more comfortable with this OON provider after previous experiences. The Plan denied your request. The Plan says they have in-network providers available to provide the care you require.

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 care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve the hernia repair surgery to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64635) provided on March 15, 2021.

You asked the Plan to pay for facet joint injections. You say that this is supported by the records. The Plan denied your request. The Plan says the units billed exceeds MUE.

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 64635 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64635) provided on March 15, 2021.
Appeal type: Home Health
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 you disagree with the denial. The Plan denied your request. The Plan says
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 medically necessary. Our physician reviewer found you have knee pain and have been receiving home health skilled nursing services. The records do not support that you have complex wound care, intravenous (IV) medications, or other skilled nursing needs. The records do not support that ongoing home health skilled nursing services are reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: 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 you require inpatient acute rehabilitation in effort to facilitate increased independence and return home to your community with improved quality of life. The Plan denied your request. The Plan says that you are unlikely to tolerate an intensive rehabilitation program, do not have complex medical management needs, and do not require supervision by a rehabilitation physician.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for kidney stone, anemia and a urinary tract infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided on April 26, 2021.
You asked the Plan to pay for the services provided. You say that the correct code was billed. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.
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 96401 is Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.
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 provided. Our reviewer found that Prolia (Denosumab) improves bone mass and increases bone mineral density and should not be reported with a CPT code for chemotherapy administration.
There is a more appropriate code to report for this service. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy services provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), provided on June 8, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you received the service out-of-network.
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. Specifically, you received the service from an out of network provider. This means the service is not covered under your benefit Plan. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on May 4, 2021.

You asked the Plan to pay for the consultation. You say that you feel the office visit/consultation was necessary prior to a surgical procedure and should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 consultation (D9310) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure (97110) provided April 9, 2021.
You asked the Plan to pay for therapeutic procedure. You say that this claim was denied incorrectly without appropriate review of the medical records. Please go through the attached medical record and reprocess the claim towards necessary payments. The Plan denied your request. The Plan says code not appropriate for service billed
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 97110 GP CQ KX (4 Units) is therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility We find that CPT code 97110 GP CQ KX (4 Units) is not supported in the medical record. Specifically, the records indicate that the service is performed by a physical therapist in a home health or hospice setting. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0157) for the billed service. Based on this information, we decided that Medicare rules for coverage of therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure (97110) provided April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950), provided on April 29, 2021.
You asked the Plan to pay for the core buildup. You say that the service was medically necessary. The Plan denied your request. The Plan says your Plan does not cover this 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. 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 core buildup (D2950), provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 6, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99213). You say that the treatment was indeed medically necessary, and authorization was assumed included in the facility authorization. The Plan denied your request. The Plan says prior authorization was not requested as required.
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 services at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 6, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 21 and 28.
You asked the Plan to pre-approve the crowns. You say that your dentist told you that you need these crowns, and that your dentist also recommends them for you. The Plan denied your request. The Plan says tooth #'s 21 and 28 do not meet the criteria for approval.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that crowns for tooth #'s 21 and 28 are not medically necessary. Our physician reviewer found the provided x-rays reveal minimal decay on tooth #21 on the mesial aspect. Our reviewer found that tooth #28 is not clearly seen, but from what can be seen there is no noted structural damage present. Our physician reviewer also found that
in this instance #21 is readily restorable with a conventional restoration, and #28 does not clearly need to be restored. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 21 and 28.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radioactive tracer for identification of sentinel node injection services coded 38792 provided on March 2, 2021.
You asked the Plan to pay for the radioactive tracer for identification of sentinel node injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 38792 for the radioactive tracer for identification of sentinel node injection services has a bundled relationship with code 38900 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the radioactive tracer for identification of sentinel node injection services coded 38792 provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventative procedure (D1999), topical fluoride (D1206), prophylaxis (D1110), intraoral periapical radiographic image (D0220 and D0230) and the periodic oral evaluation (D0120), provided on March 17, 2021.
You asked the Plan to pay for the routine dental services. You say that your provider has not opted out of Medicare. The Plan denied your request. The Plan says the provider has opted out of Medicare.
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. Specifically, the provider has opted out of Medicare. This means the services are not covered by Medicare or your Plan. Therefore, we decided that the Plan does not have to pay for
the preventative procedure (D1999), topical fluoride (D1206), prophylaxis (D1110), intraoral periapical radiographic image (D0220 and D0230) and the periodic oral evaluation (D0120), provided on March 17, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no daily skilled nursing or therapy need.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.