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

We decided that the Plan does not have to pay the nursing facility care supervision (99390) provided on March
26, 2021.

You asked the Plan to pay the nursing facility care supervision. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says CPT code 99380 is a bundled
code.

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 99380 is supervision of a nursing facility patient (patient
not present) requiring complex and multidisciplinary care modalities involving regular development and/or
revision of care plans by that individual, review of subsequent reports of patient status, review of related
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.

We find that CPT code 99380 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99380 has a status indicator of B. This means that payment for CPT code 99380 is always bundled into another procedure or service. Based on this information, we decided that Medicare rules for coverage of the nursing facility care supervision have not been met. Therefore, we decided that the Plan does not have to pay the nursing facility care supervision (99390) provided on March 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc. Our reviewer says that the requirements for coverage of Synvisc have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. While the records show that the enrollee has failed Monovisc, they do not show that Orthovisc would likely be less effective or have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF)
admission and services provided February 18, 2021, to February 28, 2021 by an out-of-network (OON)
provider.
You asked the Plan to waive the coinsurance for the SNF admission and services. You say that you checked
online, and it said that the provider was in-network with 100% coverage for the first 20 days. The Plan denied
your request. The Plan says this provider is not part of the Plan's network. The coinsurance was applied
correctly to the OON services.
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 per day for days 1-100 for SNF care.
You have been asked to pay a total of $4,670.30 ($9,340.61 total cost x 50% coinsurance = $4,670.30) for the
SNF care. The SNF care falls within the Skilled nursing facility (SNF) care benefit category. The services in
this case were provided out-of-network. 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 coinsurance for the skilled
nursing facility (SNF) admission and services provided February 18, 2021, to February 28, 2021 by an out-ofnetwork
(OON) provider.
Your complaint about potentially being provided incorrect information online or the provider potentially
submitting an incorrect ID number is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the binocular microscopy service you
received on June 3, 2021.
You asked the Plan to waive the copayment for the binocular microscopy. You say that the cost of this test
should be included in the office visit copayment. The Plan denied your request. The Plan says you were
charged this copayment 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 $20
copayment for outpatient diagnostic tests.
You have been asked to pay a $20 copayment for the binocular microscopy. the binocular microscopy falls
within the outpatient diagnostic tests benefit category. Plans are permitted to charge separate copayments for
Diagnostic tests performed during an office visit. 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 the binocular microscopy service you received
on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi electric hospital bed (E0261) and dry pressure mattress (E0184).
You asked the Plan to pre-approve the hospital bed and mattress. You say that you are on oxygen full time and you require this bed. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria for the requested hospital bed and mattress.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 hospital bed and mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's condition does require position of the body in ways not feasible in an ordinary bed. The enrollee does not, however, require frequent changes in body position or need for immediate changes in body position based on the provided documentation. The enrollee appears to not be completely immobile. The enrollee's condition does require special attachments that cannot be fixed and used on an ordinary bed. The semi-electric hospital bed is not medically necessary for this enrollee. There was no indication that the enrollee could not perform a functional change of position without the electric adjustment capability. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage for the group 1 mattress as there was no evidence of a poorly healing ulcer as required. 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 hospital bed and mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve semi electric hospital bed (E0261) and dry pressure mattress (E0184).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the chiropractic services you received on July 21, 2021, and July 28, 2021.
You asked the Plan to waive the cost sharing for the chiropractic services. You say that Medicare covers these services. The Plan denied your request. The Plan says your remaining deductible and coinsurance on the amount remaining after the deductible was charged 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 20% coinsurance for chiropractic services. The contract also says that you have a $250 deductible.
As of the July 21, 2021 date of service, you had $9.21 remaining on your $250 deductible. So, the Plan charged you this $9.21. The remaining charges the chiropractic services on this date were assessed 20% coinsurance totaling $3.49. For date of service July 28, 2021, since you had met your deductible at that point, you were only charged 20% coinsurance for that date ($7.68) 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 the chiropractic services you received on July 21, 2021, and July 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on November 14, 2020.
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 this claim must be submitted to Original Medicare first for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on November 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has had imaging in January 2020 that shows multi-level degenerative disease and spinal stenosis of varying degrees, including mild to moderate at the level being treated. The record does not state that the enrollee is not indicated for operative treatment at more than two levels. The elements of the coverage criteria are not satisfied.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the abdomen coded as 76705 provided on May 25, 2021.

You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like this claim reprocessed for medical necessity. 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 the ultrasound of the abdomen has a bundled relationship with code 76705 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 of the abdomen coded as 76705 provided on May 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 the enrollee cannot adequately recover in a less intensive setting. The Plan denied your request. The Plan says the enrollee does not have medical complexities.
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 there are no complex nursing or rehabilitation needs. The patient does 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 this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aid repair services provided on
April 29, 2021.
You asked the Plan to reimburse you for hearing aid repair services. The Plan denied your request. The Plan says you have exceeded the allowed amount for your hearing aids benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only every 3 years. We looked at the file and the Plan's rules. The file shows that the Plan reimbursed you $500 for hearing aids provided on July 26, 2018. Based on this information, we decided that the Plan's rules for coverage of hearing aid repair services have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aid repair services provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and only requires short-term additional acute care services that can safely be received at the current acute care hospital. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for additional dental services received on June 14, 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 the benefit maximum has been exceeded.
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 covers dental services with up to $2,000 allowance per year. According to the case file, the health plan has paid a total benefit of $2,000 for the 2021 year. You would be responsible for any charges beyond this point. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for additional dental services received on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on April 23, 2021.
You asked the Plan to pay for genetic testing. You say that you have no knowledge of the enrollee's coverage
prior to the specimen's arrival at the lab. The Plan denied your request. The Plan says the denial of payment for
this testing is correct, because this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that multi-gene pharmacogenomic testing panels are
billed with procedure code 81479.
We looked at the file and Medicare rules. This testing was a multi-gene pharmacogenomic panel. Therefore,
this testing was not billed with the appropriate coding. Based on this information, we decided that Medicare
rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to
pay for genetic testing provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided June 20, 2021.
You asked the Plan to pay for the office visit. You say that you believe these services were medically necessary. The Plan denied your request. The Plan says services that are primarily dental in nature are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided June 20, 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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's necessary care can be provided in an alternate 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 that 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. 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 this 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain coded as 70450 provided on May 21, 2021.

You asked the Plan to pay for the CT scan of the head or brain. 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 70450 a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) scan of the head or brain coded as 70450 provided on May 21, 2021.