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

We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided from July 26, 2021, to August 6, 2021.

You asked the Plan to waive the copayment for the skilled nursing facility. You say that the services should be covered as you were not aware of the 60-day benefit period in between admissions. 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 $184 copayment per day for days 21 to 100 for Skilled nursing facility (SNF) care.

You have been asked to pay a $184 copayment per day for 11 days of skilled nursing care, these were days 21-32 of your stay ($184 x 11 = $2,024). 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 skilled nursing facility care provided from July 26, 2021, to August 6, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF care. You say that you are requesting continued SNF care. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.  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 you meet criteria for continued skilled nursing facility (SNF) care. Our physician reviewer found the Plan received records from the SNF but did not submit them for review. The documentation provided is of insufficient quantity and quality to support the Plan's denial.  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 skilled nursing facility (SNF) care.   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 pay for the skilled nursing facility (SNF) care provided from May 20, 2021, to June 4, 2021.  You asked the Plan to pay for the SNF care provided from May 20, 2021, to June 4, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee does not require daily skilled services.  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 the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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. Specifically, the file shows that the enrollee did not receive daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 20, 2021, to June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider from August 11, 2021, through September 22, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider from August 11, 2021, through September 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-sharing for a SPECT test (78452), cardiovacsular stress test (93015), a specialist office visit (99212), a Technetium tc-99m (A9500), a regadenoson injection (J2785), and saline solution (J7050) provided on September 27, 2021.  You asked the Plan to waive the cost-sharing for the a SPECT test, cardiovacsular stress test, a specialist office visit, a Technetium tc-99m, a regadenoson injection, and saline solution. 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 s 20% coinsurance, $40 copayment, $125 copayment, and a $45 copayment for Medicare Part B Prescription Drugs, Outpatient Diagnostic Tests and Therapeutic Services and Supplies, and Physician/Practitioner Services, Including Doctor's Office Visits.      DOS CPT CODE COSTSHARING TOTAL 9/27/2021 99212 $45 copayment   9/27/2021 93015 $40 copayment  9/27/2021 A9500 Allowed $350 x 20% = $70  9/27/2021 J2785 Allowed $237.24 x 20% = $47.45  9/27/2021 J7050 Allowed $0.70 x 20% = $0.14  9/27/2021 78452 $125 copayment  Total:    $327.59   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 cost-sharing for a SPECT test (78452), cardiovacsular stress test (93015), a specialist office visit (99212), a Technetium tc-99m (A9500), a regadenoson injection (J2785), and saline solution (J7050) provided on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (93000) provided on June 3, 2021.

You asked the Plan to waive the copayment for the electrocardiogram. 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 $30 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.

You have been asked to pay a $14.45 copayment for an electrocardiogram, which is less than the $30 stated in the Plan's contract. Electrocardiograms fall 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 an electrocardiogram (93000) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81219, 81270, 81273, 81279, 81339) provided to the enrollee on April 22, 2021.  You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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.  Review of the file shoes the enrollee had molecular pathology testing on April 22, 2021. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81219, 81270, 81273, 81279, 81339) provided to the enrollee on April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. You also say that you cannot return to the shelter because you need to regain your strength. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

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 you receive oral and inhaled medications, and you have stable vital signs. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection.

You asked the Plan to pre-approve a Gel-One injection. You say that the enrollee has tried and failed conservative treatments. You say that the enrollee has had a very good response to previous injections. You say that the clinical information provided supports the need for the injection services being requested. The Plan denied your request. The Plan says the documentation provided indicate the enrollee's pain is well controlled with the medications currently being taken. The records did not include any recent non-drug therapy treatments that have been tried. The records indicate the request is in preparation for increased walking on an upcoming vacation.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations are covered when medically necessary. 

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 Gel-One injection. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation that the enrollee has failed at least three months of conservative therapy. The requested injection 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 Gel-One injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (CPT code S9328) provided to the enrollee from May 3, 2021, through May 31, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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. 

CPT code S9328 has status code of "I". Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (CPT code S9328) provided to the enrollee from May 3, 2021, through May 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation mileage
(A0170).
You asked the Plan to pre-approve additional mileage. You say that you are in a rural area and you need to see
this provider. You also say this is the closest location to your home. The Plan denied your request. The Plan
says you are requesting an additional 56 miles for a total of 106 miles and your benefit only allows 50 miles.
The Plan also says you have exceeded your benefit limit Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers up to 24 one-way trips and each one-way trip must not exceed 50 miles of driving
distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency
transportation mileage (A0170)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the home health services provided from
June 16, 2021, to July 7, 2021.
You asked the Plan to pay an additional amount for the home health services. You say that you were not told
that this provider was out of network. The Plan denied your request. The Plan says there is a $750 out of
network deductible that must be met before payment can be made. The Plan also says that the deductible had
not been met prior to the dates of service in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 out of network deductible which applies to out of network
services.
The home health services you asked the Plan to pay for were provided by an out of network provider. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies
to services that you receive out of network. This cost sharing is a contractual obligation that had not been met
at the time the home health services were received. Therefore, we decided that the Plan does not have to pay an
additional amount for the home health services provided from June 16, 2021, to July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (CPT code 76882) provided to the enrollee on September 20, 2021.

You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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, we have confirmed that code 76882 is a column II code to column I code 93925. 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 the ultrasound (CPT code 76882) provided to the enrollee on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on March 2, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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.

Targeted genomic sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on August 2, 2021.  You asked the Plan to pay for the injection of a therapeutic or diagnostic substance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include medical records to validate the medical necessity of the billed service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 62320 is not supported in the record. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the injection of a therapeutic or diagnostic substance have not been met. Therefore, we decided that the Plan does not have to pay for the injection of a therapeutic or diagnostic substance (62320) provided on August 2, 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
July 30, 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 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from December 25, 2020,
to January 23, 2021.
You asked the Plan to pay for the home health services. You say that you are a Medicare certified provider.
You also say that this claim should be paid. The Plan denied your request. The Plan says the provider in this
case is not Medicare certified. The Plan also says that payment cannot be made to providers that are not
Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the home health services provided from
December 25, 2020, to January 23, 2021
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  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 there is no evidence of complex wound care, new enteral feedings, or other skilled nursing needs. The enrollee is not on IV antibiotics and is medically stable. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require skilled nursing or skilled therapy services or a combination of these services, on a daily basis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.