Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to approve continued home health services.
You asked the Plan to approve home health services. You say that the continued care is necessary. The Plan denied your request. The Plan says home health services are no longer medically necessary.
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 approve home health services. Our reviewer says that the continued service is not medically necessary. Our physician reviewer found the enrollee is not homebound and a caregiver is able to provide the needed wound care. As such, the requested, ongoing, home health skilled services are not 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 home health services have not been met. Therefore, we decided that the Plan does not have to approve continued home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based filling (D2335) provided on April 15, 2021.
You asked the Plan to pay for the filling. You say that your dentist's office closed due to the pandemic and some of the services you received this year should have been provided last year. You feel any unused balance from 2020 should be carried over to 2021. The Plan denied your request. The Plan says you have used your full $1,000 annual dental benefit maximum. You are responsible for any amount that exceeds this limit.
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 up to $1,000 of dental care per year. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the $1,000 annual maximum are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based filling (D2335) provided on April 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Guardant360 testing (81479) provided on May 20, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says that there is not a physician order for the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have been met. Specifically, the documentation submitted clearly includes a physician order. There is no indication that this physician order is invalid. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for Guardant360 testing (81479) provided on May 20, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room services, body cat scan and magnetic imaging provided May 5, 2021, and May 6, 2021.
You asked the Plan to waive the copayments for the emergency room services, body cat scan and magnetic imaging. You say that you shouldn't have to pay so much for your emergency situation, and you were admitted due to your issues. The Plan denied your request. The Plan says the copayments were applied correctly.
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 $90 copayment for emergency services and a $200 copayment for advanced imaging services.
You have been asked to pay a total of $279 ($90 copayment for the emergency care + $189.03 copayment for the imaging services = $279.03) for the emergency room services, body cat scan and magnetic imaging. These services fall within the Outpatient hospital services benefit category. This means that you have been asked to pay less than or equal to 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 copayments for the emergency room services, body cat scan and magnetic imaging provided May 5, 2021, and May 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage (A0170).
You asked the Plan to pre-approve additional mileage. You say that you need to get to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 24 one-way trips with each one-way trip not exceeding 50 miles of driving distance.
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 routine transportation when the driving distance for a one-way trip is within 50 miles. 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, the provider is located 90 miles away from your residence. The Plan only covers distances up to 50 miles Therefore, we decided that the Plan does not have to pre-approve additional mileage (A0170).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from March 27, 2021, through April 25, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continued SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At that point, the enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from March 27, 2021, through
April 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to be at one hundred percent so you can go home. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for confusion and a lower back infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three (3) additional home skilled nursing (SN) visit(s) (CPT code G0299).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
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 services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Your condition is stable, and you have had ample time for nursing instruction and education. There is no evidence of complex wound care or other SN need. Therefore, the remaining three SN home health visits are not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve three (3) additional home skilled nursing (SN) visit(s) (CPT code G0299).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (code 70450) provided on March 16, 2021.
You asked the Plan to pay for 70450. 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 codes 70450 and 70496 have a procedure-to-procedure edit modifier of 1 and an appropriate code modifier was not 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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (code 70450) provided on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD) under anesthesia.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records do not show an appropriate trial of treatment and no other symptoms such as vomiting, weight loss, and loss of appetite.
The Plan must follow Medicare rules. Medicare rules say that LCD criteria must be met for EGD to be 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have chronic nausea, but your medication list does not include proton-pump inhibitors (PPI) therapy. Rather, you consume aspirin and narcotics that may contribute to your symptoms and the gastritis that has repeatedly been identified by prior endoscopies. Available charting does not support that your provider on September 22, 2021 initiated an appropriate trial of acid suppression at the last office visit. You have no refractory vomiting, no gastrointestinal hemorrhage, and in the absence of PPI-use cannot be classified as experiencing medically-refractory symptoms to warrant another EGD at this time. Our physician reviewer found that your condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EGD) under anesthesia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for examination services (G0101) provided to the enrollee on January 5, 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 a minor procedure that has a global surgery period of 10 days.
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 definition of code Healthcare Common Procedure Coding System (HCPCS) G0101 is "screening breast and pelvic exam." 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 services at issue in this case were not supported by the medical records. Our reviewer found CPT 56405 (incision and drainage of vulva or perineal abscess) has a global period of 10 days. The HCPCS code billed should be reported with the appropriate modifier for unrelated procedure or service.
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 examination services (G0101) provided to the enrollee on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the allergens and immunotherapy professional services (95115} provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the professional services. You say that the clinic was not aware of the contract being expired. 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 allergens and immunotherapy professional services (95115} provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81230, 81240, 81241, 81291, 81479)
provided on April 13, 2021.
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that when 2 or more codes from codes such as 81230,
81240, 81241, 81291 are submitted for the same beneficiary on the same date of service, then the lab must use
the "59" modifier with each additional service billed as an attestation that it is a distinct procedural service. The
rules also say that when billing for unlisted laboratory tests using a not otherwise classified code, field 19 of the
claim must include the specific name of the laboratory test(s) and/or a short descriptor of the test(s).
We looked at the file and Medicare rules. Codes 81230, 81240, 81241, and 81291 are not supported without the
use of modifier -59. Code 81479 is an unlisted laboratory test code that was not billed with a name or
description of the test in field 19 of the claim. Based on this information, we decided that Medicare rules for
coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for
laboratory services (81230, 81240, 81241, 81291, 81479) provided on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery and ophthalmologist services provided from April 5, 2021, through April 21, 2021, by out-of-network providers.
You asked the Plan to pay for the services. You say that you were assigned a primary doctor that was no longer a participating doctor. The Plan denied your request. The Plan says the providers are out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 cataract surgery and ophthalmologist services provided from April 5, 2021, through April 21, 2021, by out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmological medical exam and evaluation (92014), scanning computerized ophthalmic diagnostic imaging (92133), and the laboratory services (83516, 83861) provided on May 18, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 each Medicare-covered specialist office visit. You must pay a $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests. Additionally, you must pay a $10 copayment for Medicare-covered laboratory services. You have been asked to pay $65 which includes a $30 copayment for the specialist office visit, a $25 copayment for the diagnostic imaging service, and a $10 copayment for the laboratory services provided. 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 copayments for the ophthalmological medical exam and evaluation (92014), scanning computerized ophthalmic diagnostic imaging (92133), and the laboratory services (83516, 83861) provided on May 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for dialysis treatment for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this treatment should be received from 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for dialysis treatment for the enrollee.