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

We decided that the Plan does not have to pay for the nursing facility care provided from April 6, 2021, to April 28, 2021.

You asked the Plan to pay for the nursing facility care. You say that the enrollee had revoked hospice on April 3, 2021. You also say that the claim should be paid by the enrollee's plan. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.

The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on April 3, 2021. The services in question were provided before the end of that month. The record also shows that the enrollee re-enrolled in hospice on on April 28, 2021. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided from April 6, 2021, to April 28, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for the outpatient services provided from August 6, 2021, through August 30, 2021.

You asked the Plan to waive the copayment for the outpatient services. You say that you needed the device to help get through scar tissue while it's healing. You say that you are on a fixed income and the cost is very difficult. The Plan denied your request. The Plan says that the copayments applied correctly.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a claim form, Explanation of Benefits or Remittance advice to show what was billed and how many services were billed. This means that we cannot determine the copayment you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the copayment for the outpatient services provided from August 6, 2021, through August 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF)  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there have been no acute changes for a need to be upgraded to subacute care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested continuation of skilled nursing facility services is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the crown (D2790) provided on March 23, 2021, by an out of network dentist.

You asked the Plan to reimburse an additional amount for the crown. You say that you were advised by a plan representative that since you used an out of network provider, only half of the 50% shown in your policy would be paid. You say that your policy says that providers are based on MAC (Maximum Allowable Charge).

You say that 50% should be paid in or out of network. You also say that the dentist clearly noted that the core build up was necessary. The Plan denied your request. The Plan says you may be billed by the out of network provider for any amount greater than the payment made by the plan to the provider. The Plan also says that the claim was processed correctly.

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 and the crown is listed as covered, there is a 50% coinsurance for the crown. Additionally, out of network providers may bill you for any amount greater than what the Plan pays the provider.

Therefore, we decided that the Plan does not have to reimburse an additional amount for the crown (D2790) provided on March 23, 2021, by an out of network dentist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 5, 2021.

You asked the Plan to pay for the services. You say that this was performed for better evaluation of the enrollee's condition. The Plan denied your request. The Plan says the services were not authorized.

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 laboratory services provided to the enrollee on January 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound examination (76700) provided on August 17, 2021.

You asked the Plan to pay for ultrasound 76700. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 76700 has a procedure-to-procedure (PTP) edit of 1 with code 93976 so is not separately payable without an appropriate modifier.

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 ultrasound 76700 is a column II code to column I code 93976. 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 examination (76700) provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic cardiovascular risk assessment testing provided to the enrollee on June 11, 2021.  You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.     Our physician reviewer found Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease. Medicare denies coverage for all cardiovascular risk screening assessment genomic testing panels for suspected or documented cardiovascular disease. Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride every 5 years, as cardiovascular screening testing. The review has determined that the services at issue in this case are 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic cardiovascular risk assessment testing provided to the enrollee on June 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (97140, 97161, 97530) provided on June 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for out-of-network physical therapy. You say that these services were medically necessary. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The services provided in this case were not pre-approved or urgent/emergent and could have been performed by an in-network provider.  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 physical therapy services (97140, 97161, 97530) provided on June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing provided to the enrollee on February 13, 2020.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing provided to the enrollee on February 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 6, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an unbundled 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.      In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 imaging services (procedure code 70450) provided to the enrollee on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90846) provided June 7, 2021 to July 14, 2021.

You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network and the provider is not eligible for Medicare payment.

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 these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90846) provided June 7, 2021 to July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tympanostomy services coded 69436 provided on June 1, 2021.  You asked the Plan to pay for the tympanostomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed in an incorrect place of 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.  In this case, the CPT Code Manual definition of code 69436 is tympanostomy (requiring insertion of ventilating tube), general anesthesia.   We find that CPT code 69436 is not supported in the medical record. Specifically, this service was billed with place of service 11 (office). This service is listed as one that is not allowed in this place of service. That means this code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the tympanostomy services have not been met. Therefore, we decided that the Plan does not have to pay for the tympanostomy services coded 69436 provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) and oral hygiene instructions (D1330) provided on September 22, 2021  You asked the Plan to pay for the prophylaxis (D1110) and oral hygiene instructions (D1330). You say that the scheduling of this procedure was the responsibility of the dentist. You say that they always create a problem charging for the toothbrush instructions and you don't understand this. The Plan denied your request. The Plan says the services are not covered benefit.  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 two cleanings per calendar year. The Plan paid for the prophylaxis provided on January 27, 2021 and May 21, 2021, which exhausted your benefit. The oral hygiene instructions (D1330) remain denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and oral hygiene instructions (D1330) provided on September 22, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood count services received on October 9, 2020.

You asked the Plan to pay for the blood count services. You say that you feel this service should be covered under your wellness preventive. The Plan denied your request. The Plan says the services received 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 blood count testing at issue in this appeal was 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 blood count services received on October 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need to get stronger. The Plan denied your request. The Plan says your needs are custodial.  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 services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a minimal to maximal assist level for functional mobility. You require varying assist with activities of daily living. There are no identifiable 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 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 27, 2021.  You asked the Plan to pay for the ambulance service. You say that you were feeling weak and had hot flashes a few days after receiving your vaccine. You say that a few weeks later you received a bill for the paramedics checking on you. You also say that you should not have to pay this bill. The Plan denied your request. The Plan says there was no transport provided. The Plan also says that since there was no transport provided, there are no payable services.    The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 27, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care provided from March 27, 2020

You asked the Plan to pay for the custodial care. You say that you feel this should be covered by the plan. You say that you did not have anywhere else to go. You also say that no other facility would take you due to the coronavirus. The Plan denied your request. The Plan says custodial care is not covered by the Plan or Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Additionally, the record shows that you opted to self-pay for the services you received on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the custodial care provided from March 27, 2020
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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.