Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another setting.  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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the drug test and to pay for the specimen handling services received on August 16, 2021.

You asked the Plan to waive the coinsurance for the drug test and to pay for the specimen handling services. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the services have been processed correctly per your plan benefit.

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 50% coinsurance for diagnostic procedures and tests received from an out-of-network provider.

You have been asked to pay 50% coinsurance for the drug test and to pay for the specimen handling services. The drug test falls within the diagnostic procedures and tests received from an out-of-network provider 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. The specimen handling services are not a covered service. This means you are liable for this amount. Therefore, we decided that the Plan does not have to waive the coinsurance for the drug test and to pay for the specimen handling services received on August 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the EGD provided on July 1, 2021.  You asked the Plan to waive the deductible for the EGD. You say that the endoscopy and the colonoscopy are both preventive. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 deductible which applies to the EGD.   The EGD you asked the Plan to waive the deductible for falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to the EGD. The record shows the EGD is considered a diagnostic service. This cost sharing is a contractual obligation that had not been met at the time the EGD was received on July 1, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the EGD provided on July 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the bamlanivimab infusion provided on January 25, 2021.  

You asked the Plan to pay for the bamlanivimab infusion. You say that this was coronavirus related and should be covered. The Plan denied your request. The Plan says this is covered under Medicare Fee for Service and should not be paid by the Plan.  

The Plan must follow Medicare rules. Medicare rules say that for patients enrolled in a Medicare Advantage Plan in 2020 and 2021, submit claims for administering COVID-19 monoclonal antibody products to Original Medicare through your Medicare Administrative Contractor (MAC).   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bamlanivimab infusion have not been met. Specifically, Original Medicare is responsible for payment and you can contact the facility to inform them to submit the bill to your Original Medicare contractor. Therefore, we decided that the Plan does not have to pay for the bamlanivimab infusion provided on January 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need two (2) weeks of therapy. The Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy in a SNF 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 daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are non-ambulatory at baseline and unable to follow commands for skilled therapy. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and orthodontic retention provided on August 16, 2021.

You asked the Plan to pay for the limited oral evaluation, intraoral x-ray, and orthodontic retention. You say that you pushed your teeth out of alignment and could not close your mouth properly to chew. You say that this was medical treatment versus dental treatment and should be covered. The Plan denied your request. The Plan says an oral exam is only covered once per year. The Plan also says that the intraoral x-ray and orthodontic retention are also denied as non-covered benefits.

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 also have a maximum benefit of one oral exam per calendar year. The Plan paid for the oral exam provided on January 21, 2021, which exhausted your benefit. The intraoral x-ray and orthodontic retention remain denied as non-covered benefits. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and orthodontic retention provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, 83970, and 84100) provided to the enrollee on February 8, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. The documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of ESRD. Therefore, in accordance with CMS, the laboratory tests are the responsibility of the dialysis center and are not separately reportable by the laboratory. Note that the claim included one or more laboratory tests that were not edited during the earlier claim review. These laboratory tests may not all be separately reported under the CMS policy, but we are not applying any new edits on the claim at this time. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 83550, 83970, and 84100) provided to the enrollee on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) treatments.

You asked the Plan to pre-approve the TMS treatments. You say that it is felt that this is medically necessary for the enrollee's treatment. The Plan denied your request. The Plan says the rules for this coverage are not met.

The Plan follows Medicare rules. Medicare rules say that rTMS may be covered for enrollees who have undergone a trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably measure depressive symptoms. 

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 TMS treatments. Our reviewer says that the Medicare criteria for the requested TMS treatments are not met in this case. Our physician reviewer found based on the information provided, this patient does meet the clinical criteria for the use of TMS therapy utilizing LCD L33398 as she has tried several different anti-depressant agents but has not undergone adequate psychotherapy or electroconvulsive therapy. Utilizing the information from this enrollee that indicates this patient does have an indication for the requested Repetitive Transcranial Magnetic Stimulation (rTMS). However, this patient does not meet the criteria for Repetitive Transcranial Magnetic Stimulation (rTMS) therapy at this time. 

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 TMS treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) treatments.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for a general health panel (80050) provided from June 30, 2021, to July 1, 2021.

You asked the Plan to hold you harmless for a general health panel. You say that you were not aware this would not be covered. The Plan denied your request. The Plan says that this is not covered.

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 follows these rules. 

You were referred for a general health panel by a contract provider. The file does not show that the Plan provided notice that a general health panel would not be covered. Under Medicare rules, this means a general health panel is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a general health panel (80050) provided from June 30, 2021, to July 1, 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: 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 enrollee needs to progress to become as independent as possible. The Plan denied your request. The Plan says the enrollee will not need or benefit from the intensity of services of an IRF.

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 physician reviewer found that in this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. She continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement. However, there is no indication that she would require skilled rehabilitation services 15 hours a week, under the supervision of a physician. She is ambulating independently and is able to accomplish toileting independently. She is at or near her prior level of function. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for set-up portable x-ray equipment (Q0092) radiologic examination, chest (71045) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on May 28, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the portable x-ray services. You say that the enrollee is at a skilled nursing facility and the services were necessary at the skilled nursing facility that the enrollee resides. 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 set-up portable x-ray equipment (Q0092) radiologic examination, chest (71045) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on May 28, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission.   Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine received on June 1, 2021.

You asked the Plan to pay for the Tdap vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine received on June 1, 2021.

Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation (RFA) of the genicular nerves.  

You asked the Plan to pre-approve the genicular nerve RFA procedure. You say that this is medically necessary for treatment of the enrollee's pain. The Plan denied your request. The Plan says the clinical documentation provided and reviewed shows that there is a lack of literature with true head-to-head comparisons to other standard treatments.  

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 the genicular nerve RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve ablations are considered experimental/investigational in nature.  The requested radiofrequency ablation of the genicular nerves are not reasonable and 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 the genicular nerve RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent hospital care (CPT code 99232) provided to the enrollee on February 1, 2021, by an out-of-network provider.  You asked the Plan to pay for the services. You say that you should not have to pay anything. The Plan denied your request. The Plan says this will need to be sent to the insurance carrier from the initial date of admittance.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, this will need to be sent to the insurance carrier from the initial date of admittance. Furthermore, this provider is not in-network with this health plan. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (CPT code 99232) provided to the enrollee on February 1, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scan of the head (70544) provided July 28, 2021.  You asked the Plan to pay for MRA scan of the head. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.  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 70544 is a column II code to column I code 70553. 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 magnetic resonance angiography (MRA) scan of the head (70544) provided July 28, 2021.