Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for GeneSight testing provided on April 30, 2021.  You asked the Plan to pay for pharmacogenomic testing. You say that no basis exists for the Plan to deny coverage of this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not meet the clinical criteria for this testing.  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.  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 Plan did not submit documentation of prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. 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 April 30, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on July 21, 2021.  You asked the Plan to pay for the dental cleaning. You say that you do not understand why this claim was denied. The Plan denied your request. The Plan says your dental benefit can cover two standard adult dental cleanings per plan year. You had two previous cleanings (D1110) on January 12, 2021, and April 14, 2021, which were covered by the Plan. Therefore, the cleaning provided on the date in question exceeded the frequency limitation of your benefit and will not be covered.  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 can cover two standard adult dental cleanings (D1110) per plan year.  Though the Plan offers a dental benefit in excess of Medicare coverage, the cleaning is requested in a frequency that is not covered under this benefit. Documentation shows that you have had two previous cleanings in 2021, which were both covered by the Plan. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76882) provided on May 7, 2021.

You asked the Plan to pay for an ultrasound. You say that this service was performed. The Plan denied your request. The Plan says this service is 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 76882 is a column II code to column I code 76642, which was previously billed by the same physician on this date of service and paid. 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 ultrasound (76882) provided on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (31600) provided on June 7, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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.  In this case, the CPT Code Manual definition of code 31600 is "Tracheostomy, planned (separate procedure)."  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 use of code 31600 is not supported by the records provided. Our reviewer found that the documentation does not include tracheostomy procedure. The records document "Trached on 6/7." As this procedure was not documented, the procedure would not be covered.  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 the services (31600) provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87507) provided October 27, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.

The Plan follows Medicare rules. Medicare rules say that this test is covered for enrollees who have acute or persistent diarrhea or paralytic ileus.

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 lab services. Our reviewer says that the lab services were not medically necessary. Our physician reviewer found the records did not show that the member had acute or persistent diarrhea nor a paralytic ileus. 

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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87507) provided October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve components of an endoskeletal knee-shin system (L5828, L5845, L5848, and L5856) and a flex-walk system (L5981).  You asked the Plan to pre-approve components of an endoskeletal knee-shin system and a flex-walk system. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.  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 components of an endoskeletal knee-shin system and a flex-walk system. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that your functional level is consistent with K3 ambulation. The physician note on June 1, 2021, indicates that if you have to walk a long distance you will have to use a cane even with the prosthetic, which does not support that you are a K3 ambulator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of components of an endoskeletal knee-shin system and a flex-walk system have not been met. Therefore, we decided that the Plan does not have to pre-approve components of an endoskeletal knee-shin system (L5828, L5845, L5848, and L5856) and a flex-walk system (L5981).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (86001) provided April 12, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 86001 is Qualitative or Semiquantitative Immunoassays  We find that CPT code 86001 is not supported in the medical record. Specifically, the laboratory report does not include documentation of this laboratory test, and therefore it cannot be verified as performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (86001) provided April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF).  You asked the Plan to pre-approve the services. You say that this is medically necessary, as you are still using a wheelchair. The Plan denied your request. The Plan says there is no need for skilled 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 services. Our reviewer says that the requested continuation of services is not medically reasonable or necessary. Our physician reviewer found you no longer qualify for SNF coverage, as you do not have documented skilled nursing or skilled therapy needs. You appear to have reached a plateau in function given your ongoing weight-bearing restriction. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care, such as home with services, assisted living, or long-term 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued services at a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interrogation device evaluation (in person) with analysis, review and report by a physician (93292) provided on June 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for Interrogation device evaluation. You say that you provided this service out of good faith, therefore you expect proper reimbursement of your service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation (in person) with analysis, review and report by a physician (93292) provided on June 24, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from May 13, 2021, through  May 17, 2021 and May 21, 2021, through May 31, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says there are no daily needs.  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 SNF services provided from May 13, 2021, through May 17, 2021 and May 21, 2021, through May 31, 2021. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from May 13, 2021, through May 17, 2021 and May 21, 2021, through May 31, 2021. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment provided from May 13, 2021, through May 17, 2021 and May 21, 2021, through  May 31, 2021. Daily skilled services were not required from May 13, 2021, through May 17, 2021 and May 21, 2021, through May 31, 2021. As a practical matter, the enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from May 13, 2021, through May 17, 2021 and May 21, 2021, through May 31, 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 SNF services provided from May 13, 2021, through May 17, 2021 and May 21, 2021, through May 31, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from May 13, 2021, through May 17, 2021 and May 21, 2021, through May 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 18 additional skilled nursing visits in the home.  You asked the Plan to pre-approve the additional skilled nursing visits. You say that you were told your wounds were chronic and would not show improvements. The Plan denied your request. The Plan says to receive more visits, your provider may submit a new request based on an updated examination and assessment of your condition.   The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 additional skilled nursing visits. Our reviewer says that the additional skilled nursing visits are not medically reasonable or necessary for you. Our physician reviewer found you are noted to have a chronic right lower extremity wound. An old black and white photo indicates that the affected area is large, but descriptions and measurements of the wound are lacking. Our reviewer found that there is no evidence that the wound is deep or healing. You are to receive wound care thrice weekly.  In between this scheduled care, the enrollee's caregivers are not tending to the wound or dressing. Our physician reviewer also found that in the absence of documented progress or basic layperson first aid/care, ongoing home health skilled nursing services are not shown to be medically necessary or reasonable.  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 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 additional skilled nursing visits in the home.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal surgery.

You asked the Plan to pre-approve a spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is experimental. More research is needed to show safety and efficacy of interspinous implants. 

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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal surgery.
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 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 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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 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 debridement of bone (11044) debridement of muscle and/or fascia (11043) debridement, subcutaneous tissue (11042) chemical cauterization of granulation tissue (17250) provided on June 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the wound care services. You say that due to the enrollee's medical condition, your physician provided care in good will without requesting an authorization to avoid delay in care which could result in medical complications. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for debridement of bone (11044) debridement of muscle and/or fascia (11043) debridement, subcutaneous tissue (11042) chemical cauterization of granulation tissue (17250) provided on June 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 1, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 7, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 7, 2021.